Form Tx-72000 - Humana Employee Enrollment Form - Dental, Life, Vision - 2008
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Humana Employee Enrollment Form - Dental, Life, Vision
TEXAS
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.
PPO and Classic Medical plans, Life and Vision plans insured or administered by Humana Insurance Company. HMO plans offered by Humana Health Plan of
Texas, Inc., a Health Maintenance Organization. POS plans offered by Humana Health Plan of Texas, Inc., a Health Maintenance Organization and insured or
administered by Humana Insurance Company. Prepaid and AdvantagePlus dental benefits offered and administered by DentiCare, Inc. (d/b/a CompBenefits).
All other Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company. CompBenefits Vision plan insured and
administered by CompBenefits Insurance Company.
Please print clearly and fill in each applicable circle.
Proposed Effective Date: _ _ / _ _ / _ _ _ _
Company name
Company city
State
Enrollment Information
Height
Weight
Full-time
Disabled?
Relationship
Last name, First name MI
Gender
student?
Date of birth
If yes, indicate reason.
(ft / in)
(lbs.)
Reason:
m F
m N
Employee
/
_ _ / _ _ / _ _ _ _
N/A
m M
m Y
Reason:
m F
m N
Spouse
/
_ _ / _ _ / _ _ _ _
N/A
m M
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Other (specify):
Reason:
m F
m N
m N
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
EMPLOYEE INFORMATION:
HOURS WORKED PER WEEK:
DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _
m RETIREE
SSN #
Street address
APT / Suite / Box
City
State
Zip code
Phone # (
)
Language: m English m Spanish
Email address
Do you have a disability that affects your ability to communicate or read? m N m Y
TX-72000-EI 5/2008
Dental
Group #:
Benefit #:
Class/Div:
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
Prior dental coverage during the past 12 months (individual or other group coverage)?
m N m Y
Prior coverage type:
Prior dental insurance carrier name
Effective date
Policy #
_ _ / _ _ / _ _ _ _
m Employee only
m Employee and spouse
Prior orthodontia coverage in the past 12 months?
Term date
Prior carrier phone # (
)
m Employee and child(ren)
m N m Y
_ _ / _ _ / _ _ _ _
m Family
TX-72000-HD 5/2008
Basic Life
Group #:
Benefit #:
Class/Div:
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
Basic dependent life? m No m Yes
Class (employer will provide you
Annual salary (if applicable)
with this information if needed)
$
If no, complete waiver section.
TX-72000-BL 5/2008
Voluntary Life
Group #:
Benefit #:
Class/Div:
Voluntary employee life
Amount (min $15,000)
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
coverage? m N m Y
$
Voluntary spouse life
Amount (min. $5,000)
Voluntary child(ren) life coverage?
Annual employee salary (if applicable)
coverage? m N m Y
$
m N m Y
$
TX-72000-VL 5/2008
TX-72000 5/2008
1
Reorder# TX-51340-HD 11/2008
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