Form Gr-67834-16 - Aetna New York Employee Enrollment Form Page 2
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3C. Individuals Covered -
List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
NOTE FOR MEDICAL COVERAGE: While the Federal Patient Protection and Affordable Care Act mandates coverage of dependent children up to age 26, your plan may
allow coverage beyond age 26. Some exceptions apply. Please refer to your plan documents or contact your benefits administrator.
Primary Office ID
Dental Office ID
Sex
Social Security
Birthdate
Coverage
Number
Number
Name (Last, First, M.I.)
M/F
Number
(MM/DD/YYYY)
Election
(if applicable)
(if applicable)
Employee
Medical
Yes Yes
Yes Yes
Yes
Yes
Yes
Dental
1.
N/A
N/A
Life/Dis
Spouse/Domestic Partner
Medical
Dental
N/A N/A
2.
Life
Child
Medical
Dental
3.
Life
Child
Medical
Dental
4.
Life
D. Declination/Waiver of Coverage -
To be completed if medical and/or dental coverage is declined or refused by an eligible employee and/or their eligible family members.
Reason for Declining Coverage (If applicable, please attach front/back of your health coverage ID card.):
1. Medical Coverage Declined for:
Myself
Spouse/Domestic Partner
Covered by spouse/domestic partner's group coverage - Carrier Name and ID
Dependents
Enrolled in other Insurance Carrier Plans - Carrier Name and ID
2. Dental Coverage Declined for:
Medicare
Covered by TRICARE or CHAMPVA
Other
Myself
Spouse/Domestic Partner
Spouse/Domestic Partner covered by employer's group medical coverage
Dependents
Spouse/Domestic Partner covered by employer's group dental coverage
I acknowledge I have been given the right to apply for this coverage, however, I am electing not to enroll. By declining this group coverage I acknowledge
that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage. Pre-existing conditions, when
enrolled in this plan, may not be covered for twelve months. NOTE: If your Plan contains a pre-existing conditions provision, the pre-existing conditions
exclusion and limitation will not apply to a person under 19 years of age.
Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).
Date (Month/Day/Year)
X
Employee Signature
E. Dependent Information
Does any dependent listed in Section C live at another address?
Yes
No
If any dependent's last name differs from yours, explain the circumstances.
If Yes, who and what address?
F. Other Insurance
If you have checked "Yes" to Other Health Coverage (Section C), provide name and policy number of insurance carrier, HMO, or other source; a copy of the insurance card; and the start date of
coverage
If you have checked "Yes" to Other Dental Coverage (Section C), provide name and policy number of insurance carrier, HMO, or other source; a copy of the insurance card; and the start date of
coverage
Is your Spouse/Domestic Partner employed?
Yes
No
If "Yes," provide name and address of spouse/domestic partner's employer.
PROOF OF PRIOR COVERAGE - IMPORTANT
(Required for other than Life Insurance)
Acceptable forms of proof are:
Does anyone age 19 and over enrolling on this enrollment form have prior coverage?
1. Certificate of Creditable Coverage from prior carrier, or
Yes
No
If you answered "Yes", provide applicant names, start and end
2. Copy of ID card or most recent payroll stub showing medical
dates of prior coverage.
coverage deduction, or
3. Copy of most recent medical premium bill from prior carrier.
Failure to provide Proof of Prior Coverage may subject you or a
family member (age 19 and over) to the full pre-existing conditions
limitation with no credit for prior coverage. You may request a
Certificate of Creditable Coverage from your prior carrier. NOTE: If
your Plan contains a pre-existing conditions provision, the pre-
Proof of coverage should accompany this enrollment form for pre-existing condition credit
existing conditions exclusion and limitation will not apply to a person
credit or waiver of dental waiting period
under 19 years of age.
Conditions of Enrollment
On behalf of myself and the dependents listed on the reverse side, I agree to or with the following:
1. I acknowledge that by enrolling in the following plans, coverage is provided by the following entities (collectively referred to as “Aetna”):
●
Aetna Primary Care Plan HMO, Aetna QPOS, and Aetna NYC Community Plan
: Aetna Health Inc. and Aetna Health
SM
Insurance Company of New York
●
Aetna Managed Choice Plan PPO: Aetna Life Insurance Company
●
Life, Accidental Death & Dismemberment, DMO
, Dental PPO and all other health coverages: Aetna Life Insurance Company.
®
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GR-67834-16 (10-10)
NY
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