Subscriber Change Request Form Page 2
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3Subscriber Change Request (continued)
c Change the Supplemental Group Term Life and AD&D insurance coverage amount of the spouse or domestic partner: (provide prior coverage
amount and new coverage amount)
Prior amount of coverage: $_________ _________ ______
New amount of coverage: $________________ _________
Cancel dependent(s) – Complete section A – Requested effective date for deletions: ___________________
For Cancellation of spouse or domestic partner: (select appropriate cancellation reason and provide date of event)
c Divorce or termination of domestic partnership: Date: ___________________
c Death: Date ___________________
c Other reason (please specify) _________________________________________________________________________ Date: ___________________
For cancellation of dependent children: (select appropriate cancellation reason and provide date of event)
c Death: Date: ___________________ c Other reason (please specify) ___________________________________________ Date: ___________________
Please provide a copy of the HIPAA certificate if enrolling self and/or dependent(s) that are over age 25 as a health plan participant during open
enrollment (OE), or if you are adding dependent(s) to your coverage outside OE with a qualifying event.
Qualifying event: ____________________________________________________________________ Qualifying event date: ___________________
Note: Newborn/adopted children or children placed for adoption require a completed Subscriber Change Request to be submitted within 31 days
from the date of birth/adoption/placement for adoption to be added to your coverage.
Please be sure to return this form as the second page contains your signature, which is necessary to process these changes.
Section A
Complete this section if adding/canceling coverage for yourself or your dependents. Provide Personal Physician/Dental provider information if the change
pertains to HMO/POS/DHMO coverage. Please fill in which benefit the change applies to:
Add
Cancel
Self
c Dental
c Dental
Last name
First name
MI
Sex
c Medical
c Medical
c Vision
c Vision
Social Security number:
Date of birth (mm/dd/yyyy) ___________________
c Group Life
c Group Life
Job title/classification
Annual earnings (not including bonuses, overtime, etc.)
c Group Life/
c Group Life/
$ _______________
AD&D $
AD&D $
If adding Supp. Life and/or Supp. AD&D insurance please indicate amount requested: $ _______________
c Supp. Life
c Supp. Life
c Supp. Life/
c Supp. Life/
HMO/POS Personal Physician name
Current patient?
Dental HMO only dental provider
AD&D $
AD&D $
Doctor’s name: ________________________________
c Yes
Dental provider name:
Provider No. ___________________________________
c No
____________________________________
IPA/MG No. ____________________________________
Dental provider No. _______________
Add
Cancel
Spouse/domestic partner
c Dental
Last name
First name
MI
Sex
c Dental
c Medical
c Medical
c Vision
c Vision
Social Security number:
Date of birth (mm/dd/yyyy) ___________________
c Group Life
c Group Life
If adding Basic Life and/or Supp. AD&D insurance please indicate amount requested: $ _______________
c Group Life/
c Group Life/
If adding Supp. Life and/or Supp. AD&D insurance please indicate amount requested: $ _______________
AD&D $
AD&D $
HMO/POS Personal Physician name
Current patient?
Dental HMO only dental provider
c Supp. Life
c Supp. Life
Doctor’s name: ________________________________
c Yes
Dental provider name:
c Supp. Life/
c Supp. Life/
Provider No. ___________________________________
c No
____________________________________
AD&D $
AD&D $
IPA/MG No. ____________________________________
Dental provider No. _______________
Add
Cancel
Child
Last name
First name
MI
Sex
c Dental
c Dental
c Medical
c Medical
c Vision
c Vision
Social Security number:
Date of birth (mm/dd/yyyy) ___________________
c Life
c Life
‡
‡
If adding Supp. and/or Supp. Life insurance please indicate amount: $_____________($5,000 or $10,000)
c Supp. Life
‡
c Supp. Life
‡
(Note: all children will be covered for the same amount for Basic Life, Supplemental Life and Supplemental AD&D coverage.)
HMO/POS Personal Physician name
Current patient?
Dental HMO only dental provider
Doctor’s name: ________________________________
c Yes
Dental provider name:
Provider No. ___________________________________
c No
____________________________________
IPA/MG No. ____________________________________
Dental provider No. _______________
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