What is required before approval and final rates can be determined by US Health and Life Insurance Company

• Employer Group Application (42KB PDF) completed and signed by Employer.
• Agent Application (39KB PDF) completed and signed by agent.
• Employee Enrollment Forms (77KB PDF) completed and signed by each Employee, as well as Employees in their waiting period, if their effective date is within 60 days of the group's effective date. Also, please note that if Employee is married, the spouse must also sign the application, regardless of coverage selected.
• Check for first month's premium.
• Copy of current billing statement.
• Copy of renewal letter from current carrier.
• Copy of Employer's most recent wage & tax report.
• Copy of PUP proposal quoted.
• Employee Enrollment Forms (77KB PDF) completed by all COBRA Participants.
• If Employer would like SecureOne to administer COBRA, a COBRA Administration Agreement (30KB PDF) must be completed and signed.

All Originals Must be Sent to the Underwriting Department at SecureOne.

Do not cancel current coverage until a written verification letter has been received confirming the rates, plan design and effective date.