Form Gr-68126 - Life And Disability Enrollment/change Request
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3Life and Disability Enrollment/Change Request
Aetna Life Insurance Company
151 Farmington Avenue
Aetna Life Insurance Company
Hartford, CT 06156
(
)
FAX: (
)
A. Transaction Information
1. Enrollment
Requested Employee Coverage
Requested Dependent Coverage
2. Termination (Cancel)
3. Change
(*Provide explanation in Section D, Special Remarks.)
Add Dependent(s)
(Life ONLY)
New Employee
Basic Life
Basic Dependent Life
Employee *
Retiree
Remove Dependent(s)
(Life ONLY)
Basic Dependent AD&PL/AD&D
Rehire/Reinstatement
AD&PL/AD&D
*
Employee must be enrolled
Plan Change
Supplemental Life
Supplemental Dependent Life
Effective Date (MM/DD/YYYY)
for dependent(s) to have
Increase/Decrease Benefit Amount*
Supplemental Dependent AD&PL/AD&D
Supplemental AD&PL/AD&D
coverage.
Other*
Short Term Disability
Date of Hire (MM/DD/YYYY)
Effective Date (MM/DD/YYYY)
Effective Date (MM/DD/YYYY)
Long Term Disability
B. Employer Information -
Please Print all Information
2. Control No.
1. Employer Name - Full Name of Business or Organization
Suffix
Account
3. Plan Number
4. SFO
5. Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization
6. Claim Office Code
7. Customer Code (Optional)
C. Employee Information -
Please Print all Information
3. Birthdate (MM/DD/YYYY) 4. Sex
1. Employee Social Security Number
2. Employee Name (Last, First, M.I)
5. Telephone Numbers
-
-
-
-
/
/
Home
Work
(
)
(
)
6. Employee Home Address (Number, Street, Apt. No., City, State, ZIP Code)
7. Employee Annual Earnings
8. Occupation/Title
9. Work State
$
10. Employee Coverage Amounts - Based on the requirements of your Plan, you may have to submit evidence of good health.
(Life Insurance ONLY)
Basic Life Amount
Supplemental Life Amount
Basic AD&PL/AD&D Amount
Supplemental AD&PL/AD&D Amount
$
$
$
$
11. Beneficiary Designation - If more than one beneficiary, use Special Remarks.
Dependent coverage Beneficiary is always the Employee.
(Life Insurance ONLY)
Full Beneficiary Name (First, Middle, Last)
Social Security Number of Beneficiary
Relationship to Employee
-
-
D. Covered Dependents -
Complete only if Dependent Coverage is offered under your Plan.
Check this box if you are refusing coverage for your dependents.
(Life Insurance ONLY)
(A)dd/New
Social Security Number
Relation.
Birthdate
Full Time
Basic Dependent AD&PL/
Supplemental Dependent
Basic Dependent
Supplemental
(C)hange
Code
Student
AD&D Amount
AD&PL/AD&D Amount
(If dependent has no SSN, write
Amount
Dependent Amount
(R)emove Dependent Name (First, Middle Initial, Last)
"None")
MM / DD / YYYY
Yes No
-
-
$
$
$
$
/
/
-
-
$
$
$
$
/
/
-
-
$
/
/
$
$
$
-
-
$
$
$
$
/
/
Special
Remarks
E. Certification -
Employee's E-mail Address:
Signatures Required
My signature below signifies my agreement with the statements and authorization under the Certification and Authorization section and the Misrepresentation section on the back of this form.
1. Employee Signature (Required)
Date
2. Employer Signature (Required)
Date
X
X
Please make a copy for your records.
Visit us at
GR-68126 (11-05)
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Parent category: Legal