UHA’S ONLINE EMPLOYER PORTAL ATTESTATION

By entering my username and password, I agree and certify that the following facts are accurate:

1. I am an authorized agent of the member group that has a contract with UHA Health Insurance (also known as UHA or UHA Health Insurance).
2. All information I submit meets the member group, employee and dependent, eligibility, enrollment, and termination requirements as provided in the contract with UHA.
3. I have retained the UHA forms and eligibility, enrollment and termination related documentation supporting the information I submit, including a signed copy of the UHA enrollment form completed by a subscriber.

I understand that if the above facts are not accurate, UHA may take certain actions as provided in the contract with UHA which may include rescission of UHA coverage or termination of a member group, employee(s) and dependent(s).