For on-exchange policies, please visit your carrier's state-specific website:
For off-exchange policies, please view your carrier's application agreement below:
Health Net (CA)
Conditions of enrollment
General Conditions: Health Net reserves the right to reject any application for enrollment if the applicant is not eligible for coverage due to not meeting eligibility conditions. There is no coverage unless this application is accepted by Health Net’s Membership Department and a Notice of Acceptance is issued to the applicant even though you paid money to Health Net for the first month’s premium. No other department, officer, agent, or employee of Health Net is authorized to grant enrollment. The applicant’s agent or broker cannot grant approval, change terms or waive requirements of this application. This application shall become a part of the Insurance Policy.
ANY FRAUDULENT OR INTENTIONAL MISREPRESENTATION OF MATERIAL FACTS in application materials is cause for disenrollment and rescission of the Insurance Policy during the 24-month period after the Insurance Policy is issued. Health Net may recoup from the policyholder (or from you or from the applicant) any amounts paid for covered services obtained as a result of such fraudulent or intentional misstatement of material fact.
IF SOLE APPLICANT IS A MINOR: If the sole applicant under this application is under 18 years of age, the applicant’s parent or legal guardian must sign as such. By signing, the applicant does hereby agree to be legally responsible for the accuracy of the information in this application and for payments of premiums. If such responsible party is not the natural parent of the applicant, copies of the court papers authorizing guardianship or a notarized affidavit of assumption of parent-child relationship must be submitted with this application.
IF APPLICANT CANNOT READ THE LANGUAGE OF THIS APPLICATION: If an applicant does not read the language of this application and an interpreter assisted with the completion of the application, the applicant must sign and submit the Statement of Accountability.
Important Provisions
BINDING ARBITRATION AGREEMENT: I, the applicant, understand and agree that any and all disputes between me (including any of my enrolled family members or heirs or personal representatives) and Health Net must be submitted to final and binding arbitration instead of a jury or court trial. This Agreement to arbitrate includes any disputes arising from or relating to the Insurance Policy or my Health Net coverage, stated under any legal theory. This agreement to arbitrate any disputes applies even if other parties, such as health care providers or their agents or employees, are involved in the dispute. I understand that, by agreeing to submit all disputes to final and binding arbitration, all parties including Health Net are giving up their constitutional right to have their dispute decided in a court of law by a jury. I also understand that disputes that I may have with Health Net involving claims for medical malpractice (that is, whether any medical services rendered were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) are also subject to final and binding arbitration. I understand that a more detailed arbitration provision is included in the Insurance Policy. Mandatory Arbitration may not apply to certain disputes if the Insurance Policy is subject to ERISA, 29 U.S.C. §§ 1001-1461. My signature below indicates that I understand and agree with the terms of this Binding Arbitration Agreement and agree to submit any disputes to binding arbitration instead of a court of law.
The application and this Arbitration Clause must be signed by the applicant(s). The applicant(s) must personally sign the applicant’s name in ink and agree to comply with the Arbitration Clause and the terms, conditions and provisions of the application and the Insurance Policy in order for this application to be processed. For this application to be considered, neither agent/broker nor any other person may sign this application and Arbitration Clause.
You may submit a photocopy or facsimile of the application and authorizations. *Health Net recommends that you retain a copy of this application and authorizations for your records. *
All references to “Health Net” herein include the affiliates and subsidiaries of Health Net which underwrite or administer the coverage to which this enrollment application applies. “Insurance Policy” refers to Health Net Life Insurance Company’s Individual & Family Plan Policy PPO Plan.