Fillable Form Sg.ee.16.ok - Employee Enrollment - Oklahoma

Employee Name __________________________________________________________________________________________________________

Please check the box for each coverage in which you or your dependents are enrolling.

If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount

D. Product Selection

selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability

(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.

Person

Medical

Dental

Vision

Basic Life/AD&D

Supp Life/AD&D

Employee

_____________

$_____________

Spouse/Domestic Partner

_____________

$_____________

Dependent

_____________

$_____________

Person

STD

LTD

Employee

Life Insurance Beneficiary Full Name and Address

Relationship

(if applying for Life Insurance with UnitedHealthcare)

Primary

Secondary

E. Prior Medical Insurance Information

Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?

YES (if yes, please complete this section.)

Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___

Prior coverage type:

Employee

Spouse

Child(ren)

Family

F. Other Medical Coverage Information

This section must be completed. (Attach sheet if necessary.)

On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,

including another UnitedHealthcare plan or Medicare?

YES (continue completing this section)

NO (skip the rest of this section)

Name of other carrier ______________________________________________________

Other Group Medical Coverage Information

Type

Effective Date End Date

Name and date of birth of policyholder

(only list those covered by other plan)

(B/S/F)*

MM/DD/YY

for other coverage

Employee:

Spouse Name:

Dependent Name:

*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)

S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.

F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

Medicare – Employee Information:

If enrolled in Medicare, please attach a copy of your Medicare ID card.

Enrolled in Part A: Effective Date _____________

Ineligible for Part A*

Not Enrolled in Part A (chose not to enroll)**

Enrolled in Part B: Effective Date _____________

Ineligible for Part B*

Not Enrolled in Part B (chose not to enroll)**

Enrolled in Part D: Effective Date _____________

Ineligible for Part D*

Not Enrolled in Part D (chose not to enroll)**

Reason for Medicare eligibility: