Form Gr-68126 - Life And Disability Enrollment/change Request Page 2

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Complete Form Gr-68126 - Life And Disability Enrollment/change Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Instructions -

Instructions are provided only for those fields which are not self-explanatory or for which you may need additional information.

A. Transaction Information

To Enroll

To Terminate (Cancel)

• Complete Effective Date and Date of Hire in Section A - Transaction

• Complete Effective Date in Section A - Transaction Information, Number 2 and

Make sure you complete

Information.

check appropriate box.

the Effective Date in

• Check the box(es) applicable to the benefit(s) you wish to enroll for in

• Complete all blank fields in Section B - Employer Information and Section C -

Section A - Transaction

Section A - Transaction Information, Number 1 - Enrollment, Requested

Employee Information.

Information.

Employee Coverage and Requested Dependent Coverage.

• Make sure you read Section E - Certification. Sign Name and Date.

Make sure you read

• Complete all blank fields in Section B - Employer Information and Section C

To Change

Section E. Sign Name

- Employee Information.

• Complete Effective Date in Section A - Transaction Information, Number 3 and

and date.

• Complete Section D - Covered Dependents for all dependents for whom you

check appropriate box(es).

are electing coverage. Complete ALL items for each individual listed.

• Complete blank fields in Section B - Employer Information (if applicable).

• Make sure you read Section E - Certification. Sign Name and Date.

• Complete Section C - Employee Information.

• Indicate change(s) in appropriate Section(s) (B, C, D) and circle.

• Make sure you read Section E - Certification. Sign Name and Date.

B. Employer Information

Control, Suffix and Account - If this information is not preprinted, provide the complete Control, Suffix and Account numbers.

B2.

The Servicing Field

B3.

Plan Number - If this information is not preprinted, refer to the Plan Sheet to determine the correct Plan Number.

Office (B4) and Claim

B7.

Customer Code (Optional) - Provide an identifying Customer Code for the employee only if you had elected to provide this information.

Office Code (B6) are

assigned by Aetna.

C. Employee Information

Birthdate - Date of birth should include four digit year of birth.

C3.

Employee Coverage Amounts - Consult your Benefits Administrator to identify which earnings/insurance amounts need to be reported. Complete the appropriate box and

C10.

To be completed by

enter the rounded dollar amount.

Enrollee.

Beneficiary Designation - Full Beneficiary Name (First, Middle and Last), Social Security Number and relationship of the person to whom benefits will be paid in the event

C11.

of your death.

D. Covered Dependents

• Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an individual.

• Name - This must be completed for all individuals for whom you are electing or changing coverage. Please complete ALL items in Section D for each individual listed.

To be completed by

Attach another form if you are requesting coverage for additional dependents.

Enrollee.

• Relationship Code - Use ONLY: H=Husband, W=Wife, N=Divorced Spouse, S=Son, D=Daughter, Y=Sponsored Male, X=Sponsored Female. If the dependent is NOT

List only those individuals

your spouse or a biological or legally adopted child, please indicate relationship to employee in Special Remarks.

for whom you are electing/

changing coverage and

• Birthdate - Date of birth should include four digit year of birth.

complete ALL items for

• Full Time Student - Defined as: Unmarried dependent child (refer to your Summary of Coverage for age limitations), regularly attends school and depends solely on the

each individual listed.

enrollee for support. Proof from the educational institution may be requested.

• Insurance Amounts - Consult your Benefits Administrator to identify which insurance amounts need to be reported. Complete the appropriate box(es).

• Special Remarks - Use this space to provide additional information or explanations. The Tobacco Use question must be completed.

E. Certification

• Read the information contained above the space provided for your signature in Section E and the information on the back of the form.

Signatures Required

• Sign name and date the form.

V1 (11-05) GR-68126