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

Conditions of Enrollment

(continued)

2. I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and until

both the eligible employee enrollment form and employer application have been accepted and approved by Aetna. Even if

this enrollment form is approved, any material misstatements or omissions may result in future claims being contested and

the policy or my coverage under the policy being contested.

For life coverages: I understand that the effective date of insurance for myself or for any of my dependents is subject to my

being actively at work on that date. Further, I understand that any insurance subject to evidence of good health or medical

information will not become effective until Aetna gives its written consent. Life insurance is incontestable after two years from

date of issue, except for non-payment of premiums.

3. I understand and agree that this enrollment form may be transmitted to Aetna or its agent by my employer or its agent.

4. The plan certificate of coverage will determine the rights and responsibilities of member(s) and will govern in the event they

conflict with any benefits comparison, summary or other description of the plan.

5. I understand and agree that, with the exception of Aetna Rx Home Delivery, all participating providers and vendors are

independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of

Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to

change. Notice of the change shall be provided in accordance with applicable state law.

6. I understand and agree that, with certain exceptions described in the plan documents, DMO

plans only provide coverage for

referred benefits, and that, in order to be covered, services must be performed either by a participating primary care dentist or

by the participating dentist or other provider as authorized by a referral from a participating primary care dentist.

7. I understand and agree that, as described in the plan documents and when enrolled for medical coverage, any pre-existing

conditions for my spouse/domestic partner, dependents or myself may not be covered for 12 months. This does not apply to

life insurance coverage.

Misrepresentation

(This fraud warning is not applicable to an application for life insurance.)

8. Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading,

information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be

subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

I represent that to the best of my knowledge and belief all information supplied in this form is true and complete. I have read and

agree to the Conditions of Enrollment and Misrepresentation on this New York Small Group Business (2 – 50 Eligible

Employees) Employee Enrollment/Change Form. I understand that if I do not sign this form within 31 days from the date first

eligible or 31 days of the qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) I

will be considered a late enrollee and the effective date of coverage for me and my dependents may be affected. I am employed

by the employer shown on Page 1, and I am working full time at least 20 hours per week for this employer at the regular place of

business.

Employee Signature

Employee E-mail Address (optional)

Date (Month/Day/Year)

Employer Signature

Date (Month/Day/Year)

This form is attached to and made a part of the group policy.

GR-67834-16 (8-07)

NY – SGB V3

Form Gr-67834-16 - Employee Enrollment/change Form - Aetna Page 3

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