If you can`t find the form or document you`re looking for below, log on to your website for more information. 3. Use the form details to send your request by fax or email. Remember: receiving a participation agreement from us does not mean that your application has been approved. In order to shorten the onboarding time line, we send you the agreement for verification while your login application will be verified. You will receive a decision on your application use this form to request report documents (POC) if coverage is still active, or to request POLC (Proof of Lost Coverage) documents when coverage is no longer active. UnitedHealthcare Life and Disability products are supplied by UnitedHealthcare Insurance Company and some products in California by Uneimerica Life Insurance Company. Products for life and disability are provided on the LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., Texas on laSD-POL-TX (05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL (05/03) and UHCLD-POL 2/2008.
Policies have exclusions, restrictions, benefit cuts and conditions under which the policy can come into force or cease. For the full costs and details of insurance coverage, call or write to your insurance agent or company. Some products are not available in all states. UnitedHealthcare Insurance Company is headquartered in Hartford, CT and Unimerica Life Insurance Company located in Milwaukee, WI. Please return your signed contract as soon as possible. We then have it on hand, so once you have approved the application for a deposit authorization, we will be able to put your contract in place in our system. It can take up to four weeks for the installation to be completed. As soon as we have received your request for a CAQH application or approved by the state, we will send you a contract called your participation contract. This usually happens within 10 business days. If you have provided us with an email address, we will send you the DocuSign secure application contract. (For more information about DocuSign, see below) If not, we will email it to you.
This form should not be used by members of UnitedHealthcare West, Oxford, Expat and Empire Plan. Note regarding e-mail: We cannot guarantee the security of communications transmitted over the Internet. We are not responsible for the illegal activities of third parties such as criminal hackers.