Form Gn-80124-Cg - Humana Employee Change Form - Levi And Associates Insurance Page 2
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1
2Group Number
Social Security Number
Dependent Changes
Please complete this section for all dependent changes.
1
Last name
First name
MI
Date of birth
_ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
2
Last name
First name
MI
Date of birth
_ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
3
Last name
First name
MI
Date of birth
_ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
4
Last name
First name
MI
Date of birth
_ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
Signature -
please sign below if requesting changes
Employee or legal representative signature: ______________________________________________
Date: ______________________
Name and relationship of legal representative: _________________________________________________________________________
GN-80124-CG 11/2006
2
Reorder# GN-99955-CG 3/2009
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