IMPORTANT INFORMATION ABOUT THIS APPLICATION FORM

This Is Not A Contract For Coverage

This is an application for coverage only. No contract for coverage exists until UHA has completed its review and communicated to the business applicant or the applicant’s broker that a Standard Agreement for Group Health Plan will be issued. At that time, the Census Form and this Employer Application & Certification Form become part of the contract for UHA coverage.

Employers: Criteria For Coverage, Subject To Audits

UHA provides health insurance coverage only to qualified employers doing business in Hawaii. Among other requirements, employers must have and maintain a valid Department of Labor number, Unemployment Insurance, Worker’s Compensation, Temporary Disability Insurance and maintain on payroll at least one eligible employee on a UHA plan. All employers may be subject to audit at UHA’s discretion. Audits are done to ensure that employers and the individuals they enroll meet all UHA requirements and those set forth in the Hawaii Prepaid Healthcare Act (Hawaii Revised Statutes, Chapter 393) and its administrative rules.

Eligible Employees: When Coverage Starts, Criteria For Eligibility

Coverage of eligible employees begins the first day of the month after employers provide health insurance coverage for eligible employees who have been in the employer's employ at least 20 hours per week for 4 consecutive weeks. Coverage may begin earlier, on the first day of the month following employment, if the employer has a written policy for earlier coverage, the employee has met or will meet an average of at least 20 hours per week, and the employer has discussed this written policy with their UHA Account Executive upon submission of this Employer Application & Certification Form. UHA's audits may include a review of the employer's written policy.

UHA Offers Three Medical Plans

UHA offers employers UHA 600, UHA 3000, or the UHA One Plan. Please note that the UHA One Plan must be the only plan to provide medical care benefits offered to all eligible employees such that no other medical benefits plan are offered and UHA is the exclusive medical insurance carrier. If you wish to offer more than one medical benefits plan through another medical insurance carrier, then UHA One Plan may not be the best option for you.

Please select Group Size on the Instructions tab.

Please select Group Size on the Instructions tab.

Attestation: I certify that the information submitted in this application is accurate and complete.

Please check the affirmation box and type your name as your digital signature for this form. Enter your contact information and click Submit Application.

By checking this box and typing my name as my digital signature below, I affirm that the information provided in this Employer Application and Census forms are accurate to the best of my knowledge.
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Your application information will be electronically submitted to UHA Health Insurance's Sales Department and a representative will contact you within 1 business day.