Enrollment Application
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1
2ENROLLMENT APPLICATION
New
Change
Benefits Administered by CareFirst Administrators
Employee - If you are applying for coverage with your employer's benefit plan, please complete Parts 2 - 6. If you do not desire coverage under your employer's plan, please complete Parts
2, 3 (as applicable) and 7. Please print clearly. Incomplete and/or illegible forms will be returned.
Part 1 - Employment Information (TO BE COMPLETED BY THE EMPLOYER)
a) Company Name: ___________________________________ b) Subgroup: _____________________________________
c) Effective Date: ____________________________________ d) Employee Date of Hire ____________________________
e) Salary: ___________________________________________
Part 2 - Employee Information
a) Social Security Number: __________________________
b) Name: Last ___________________________________________ c) First: ______________ d) Middle: ________________
e) Street: _____________________________________________________________________ f) Gender:
Male
Female
g) City: ________________________________________________________________________h) Date of Birth: __________
i) State: ________________________ j) Zip: _________________ k) Status:
Single
Married
Divorced
Widowed
Part 3 - Coverage Information
a) Medical/[Prescription]Plan b) Dental Plan
c) Vision Plan
d) Coverage Level
[Option]
[Option]
[Option]
Employee Only
[Option]
[Option]
[Option]
Employee + Child[(ren)]
[Option]
[Option]
[Option]
Employee + Spouse
__
Employee + Family
Part 4 - Dependent Information
- Complete below unless you elected Single coverage in Part 3 above.
Last Name
First Name
Middle Name
Date of Birth Relationship Gender
Social Security Number
a)______________________________________________b) __________ c) Spouse
d)______ e) _________________
f)______________________________________________g)___________ h) _________ i)______ j) _________________
k)______________________________________________l)___________ m)_________ n)______ o) _________________
p)______________________________________________q) __________ r) _________ s)______ t) _________________
u)______________________________________________v) __________ w) ________ x)______ y) _________________
Part 5 - Other Coverage Information
a) Are you or any member of your family covered by any other group insurance, HMO Plan, or Federal program including Medicare?
Medical
Yes
No; Dental
Yes
No; Vision
Yes
No; Prescription
Yes
No (Complete below for Medicare)
b) If yes, Name of Carrier:
c) Policy ID#:
d) Address:
e) Effective Date:
f) Policyholder Name:
g) Are family members covered?
Yes
No
If yes, which ones?
Employee
Spouse
Children
If yes, is this Plan Primary (P) or Secondary (S) for:
P
S Employee
P
S Spouse
P
S Children
Medicare Part A
Yes
No; Medicare Part B
Yes
No; Medicare Part D
Yes
No
b) If yes, Name of Carrier:
c) Health Insurance Claim# (HIC#):
d) Address:
e) Effective Date Part A:
Effective Date Part B:
Effective Date Part D:
f) Policyholder Name:
g) Are family members covered?
Yes
No
If yes, which ones?
Employee
Spouse
Children
If yes, is this Plan Primary (P) or Secondary (S) for:
P
S Employee
P
S Spouse
P
S Children
M:\MASTER\CFA_Enrollment Application Template.doc
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