Form Gr-69068-5 - Aenta Enrollment Form
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4AETNA LIFE INSURANCE COMPANY
151 Farmington Avenue
Hartford, CT 06156
New York Small Group Business
Employee Enrollment/Change Form for
Medical, Dental and Vision Coverage
FOR GROUP COVERAGE (1–100 FULL TIME EQUIVALENT EMPLOYEES)
®
SM
SM
DMO
and PPO dental plans, Aetna OAMC plans, Aetna EPO plans, Aetna Indemnity, Aetna Vision
Preferred plans and Aetna NYC Community Plan
are provided by Aetna Life Insurance Company. For Vision coverage, certain claims administration services are provided by First American
Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care, LLC (“EyeMed”).
Member Aetna ID Number (if available)
INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to you
resulting in a delay in processing. You are solely responsible for its accuracy and completeness. If waiving
coverage, please complete Section E. Please use only black ink to complete this form.
Company Name
Effective Date
New Hire
Add Spouse
Employee Termination
Rehire/Reinstatement
Add Domestic Partner
Remove Spouse
New Group Enrollment
Add Dependent Child
Remove Domestic Partner
Date of Hire
Late Enrollment
Change of Coverage
Remove Dependent Child
Waiver
Name Change
Cancel Coverage
Open Enrollment
Other
Benefit Waiting Period*
Loss of Coverage
Class 1
Class 2
*only required when your employer
has 2 benefit waiting periods
COBRA
Continuation for:
Employee
Dependent
Length of Continuation:
18 months
36 months
Other
Qualifying Event
Original Qualifying Event Date
Loss of Coverage Date
A. Employee Information - Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Home Telephone
Work Telephone
Primary Language Spoken
Number of Dependents (including Spouse/Civil
(Optional)
Union/Domestic Partner) enrolling for medical
(
)
-
(
)
-
coverage
No. of Hours
Check One
Marital Status
Worked Per Week
Single
Married
Full-Time
Part-Time
1099
Retired
Divorced
Widowed
Seasonal
Temporary
Union
COBRA
Legally Separated
B. Coverage Selection (Shaded sections for Employer/Aetna Use Only)
Class Code
Control/Group No.
Suffix
Account
Plan No.
1. Medical
®
Open Access Managed Choice
(OAMC) HSA Compatible Plan Option:
®
Open Access Managed Choice
(OAMC) HSA Compatible FHPlan Option:
®
Open Access Elect Choice
(OAEPO) Plan Option:
®
Open Access Elect Choice
(OAEPO) HSA Compatible Plan Option:
®
Savings Plus Open Access Elect Choice
(OAEPO) Plan Option:
SM
NYC Community Plan
Plan Option:
Indemnity Plan Option:
Other Plan Option:
continued on next page
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GR-69068-5 (6-15)
NY R-POD
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Parent category: Business