Fillable Form Nj Hint - New Jersey Enrollment/change Request

New Jersey Small Group Enrollment/Change Request

Aetna Health Inc. / Aetna Life Insurance Company

Employer Group Information

–

To Be Completed by Employer

Aetna HMO, HNOnly, HNOption and QPOS plans are underwritten by Aetna

Group Name

Health Inc. Aetna Indemnity, OA EPO, OA MC and MC plans are underwritten by

HMO Only – Group No.

Class Code

Aetna Life Insurance Company.

PPO Only – Control No.

Suffix

Account No. Plan No.

A. Type of Activity –

To Be Completed by Employer. To Add, Change, or Remove coverage for dependents over the limiting age, but less than 31, Aetna Form

HINT Supplemental Enrollment Information Form Implementing P.L. 2005, c. 375, must be completed. Refer to instructions on Page 4 before completing this

form.

Please print clearly.

1. Enrollment

2. Change

– Check all that apply.

Date of Event

Reason

New Enrollee/Subscriber

Add Spouse/Civil Union Partner

Effective Date

Add Domestic Partner

Add Dependent Child

Name Change

Date of Hire

Change Plan

Other

Add/Change Primary Office ID Number

3. Remove or Terminate

4. Continuation of Coverage, i.e., COBRA, State, Total Disability

– Check all that apply.

- Not all options are available or applicable. Contact Employer for available options.

Effective Date

Reason

Remove Spouse/Civil Union

Coverage for:

Employee

Spouse/Civil Union Partner*

Dependent(s)

Partner*

Length of Continuation:

18 mos.

29 mos.

36 mos.

Remove Domestic Partner*

Total Disability**

Remove Dependent Child*

Date of Loss of Coverage:

Employee Withdrawal/

Date of Qualifying Event:

Termination

Qualifying Event #:

***

NOTE: Employee must be enrolled for spouse/civil union partner/dependent(s)

* Civil union partners are eligible to make an election pursuant to NJSGC, if

to have coverage.

applicable.

* Please complete Section D for each member being removed or terminated.

** Attach proof of disability.

*** Refer to list of qualifying event numbers on Page 4-Instructions section.

B. Employee Information –

Complete Sections B - I.

Social Security Number

Last Name, First Name, M.I.

Home Telephone

(

)

Home Address

Apt. No. City, State

ZIP Code

Employer Name

E-Mail Address

Work Telephone

(

)

Work Address

City, State

ZIP Code

Date of Employment

Hours Worked Per Week

C. Medical Plan Options –

Your selection must be offered by your employer.

Check One.

NJ HMO:

Plan Option:

Rx Option:

NJ HNOption:

Plan Option:

NJ HMO HSA Compatible: Plan Option:

NJ HNOption HSA Compatible:

Plan Administration:

Cal Yr

Plan Yr

Plan Option:

Rx Option:

Plan Administration:

Cal Yr

Plan Yr

NJ Savings Plus HMO:

Plan Option:

NJ Savings Plus HMO HSA Compatible: Plan Option:

NJ OA EPO:

Plan Option:

Plan Administration:

Cal Yr

Plan Yr

NJ OA EPO HSA Compatible: Plan Option:

Plan Administration:

Cal Yr

Plan Yr

NJ HNOnly:

Plan Option:

Rx Option:

NJ Aetna Whole Health (AWH) OA EPO: Plan Option:

NJ HNOnly HSA Compatible:

Plan Option:

Rx Option:

NJ MC:

Plan Option:

Plan Administration:

Cal Yr

Plan Yr

NJ OA MC:

Plan Option:

NJ Savings Plus HNOnly: Plan Option:

NJ OA MC HSA Compatible: Plan Option:

NJ Savings Plus HNOnly HSA Compatible: Plan Option:

Plan Administration:

Cal Yr

Plan Yr

Plan Administration:

Cal Yr

Plan Yr

NJ Indemnity:

Plan Option:

NJ QPOS:

Plan Option:

Other Plan:

NJ HINT - Group

SGB GR-68900-25 (8-13) V2 R-POD B

Form Nj Hint - New Jersey Enrollment/change Request - Aetna

Related Articles

Related forms

Related Categories