Fillable Form Gr-67834-16 - Employee Enrollment/change Form

C. Individuals Covered -

List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary. Height and weight information needed

for Life Insurance applicants only.

Primary Office

Dental Office ID

Sex

Social Security

Birthdate

Coverage

ID Number

Number

Name (Last, First, M.I.)

M/F

Number

(MM/DD/YYYY)

Election

(if applicable)

Employee

Medical

Yes Yes

Yes

Dental

N/A

Life/Dis

Spouse/Domestic Partner

Medical

Dental

N/A N/A

Life

Child

Medical

Dental

Life

Child

Medical

Dental

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:

Covered by spouse/domestic partner's group coverage - Carrier Name and ID

Myself

Spouse/Domestic Partner

Dependents

Enrolled in other Insurance Carrier Plans - Carrier Name and ID

2. Dental Coverage Declined for:

Medicare

Covered by TRICARE or CHAMPVA

Other

Spouse/Domestic Partner covered by employer's group medical coverage

Myself

Spouse/Domestic Partner

Spouse/Domestic Partner covered by employer's group dental coverage

Dependents

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.

Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).

Date (Month/Day/Year)

Employee Signature

E. Dependent Information

Does any dependent listed in Section C live at another address?

Yes

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

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 enrolling on this enrollment form have prior coverage?

1. Certificate of Creditable Coverage from prior carrier, or

Yes

If you answered "Yes", provide applicant names, start and end dates of

2. Copy of ID card or most recent payroll stub showing