Form Gn-80124-Cg - Humana Employee Change Form - Levi And Associates Insurance
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1
2Humana Employee Change Form
Please print clearly and fill in each applicable circle.
Current Medical Group number
Benefit number
Class/Division
Current Dental Group number
Proposed Effective Date for change: __ __ / __ __ / __ __ __ __
Company name
Company city
State
Employee Information and Changes
Please provide employee information and indicate all applicable employee changes.
Last name
First name
MI
Social Security number
m Change Medical benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change or Select Employee Primary Care Physician (HMO and POS only):
Primary care physician: ______________________________________________ Physician ID: ________________________
m Change Dental benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Change or Select Employee Primary Care Dentist (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: ___________________________________________________ Facility number: ______________________
m Change Basic Life benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change Basic Life Beneficiary: Group number: ________________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Voluntary Life Beneficiary: Group number: ____________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Vision benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Cancel My Coverage for the following products: m Medical m Dental m Basic Life m Voluntary Life m Short-term Income Protection
m Vision m Health Savings Account (HSA) m Health Care FSA m Dependent Care FSA
Qualifying Event Information
Please indicate the qualifying event date and reason for employee or dependent changes below.
Qualifying event date: __ __ / __ __ / __ __ __ __
Reason for change:
m Re-hire
m Marriage
m Spouse terminates employment
m Employer contribution ceases
m Legal separation
m Spouse’s employer terminates coverage
m Dependent birth / adoption
m Divorce
m Spouse changes from full-time to
part-time employment
m Dependent change to full-time student
m Spouse deceased
m Other: __________________________
Change Address Information
Address change applies to:
m Employee only m Employee and all covered dependents
m Only for the following dependent (please print full name): Last name
First name
MI
New street address
Apt / Suite / PO Box number
City
State
Zip code
County
Email address
Phone number
GN-80124-CG 11/2006
1
Reorder# GN-99955-CG 3/2009
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