Page 47 - SOLO Member Guidebook

HOW TO APPLY

• A dependent loses coverage because of the death of a covered employee under a group plan
• The termination (other than for misconduct) or reduction of hours of a covered employee’s
employment that results in a loss of group health coverage
• The divorce or legal separation that results in a loss of group health coverage
• A covered dependent loses group health coverage because of a covered employee’s eligibility
for Medicare
• A dependent child loses coverage due to loss of dependent status under an employee’s group
health plan

Initial Premium Payment:
Initial premium payment is required with the submission of the application in order to obtain medical
coverage. ConnectiCare offers the following payment options:

Online Application Submissions:
• Electronic Funds Transfer (EFT) from your bank account
• Credit Card

Paper Application Submissions:
• EFT
• Credit Card
• Check or Money Order
• Mail payments to:

ConnectiCare, Inc. and Affiliates
175 Scott Swamp Road
Farmington, CT 06032
Attention: Billing Department

Steps to Apply – ONLINE or PAPER:
3) Intial payment, equal to one month’s premium payment, must be submitted with the application by submitting
a check or completing either the attached EFT or credit card form. All future premium payments are due by the
first of the month. All premiums not received by the first of the month for the month of coverage are considered
past due. This applies to all premium payment methods – check, Electronic Funds Transfer (EFT) and credit
card.

3a) To elect paying your premium via EFT you may complete the EFT form as part of your application, or make
the election at a later date. There are two ways to elect EFT for future premium payments:
• Once you receive your first invoice, you can sign the return portion of your invoice and return it with your
first premium payment. For future payment drafts, we will use the checking account number that appears
on the

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