Health Insurance Enrollment Form - Mercer Administration printable pdf download

Mercer Administration, A Service of Seabury & Smith, Inc.

co. # __________ ee. # ________

A. Application Type

□ New Hire

□ Late Enrollee

□ Special Enrollee (indicate event & date below)

□ Change (indicate event & date below)

□ Open Enrollment

Event Requiring Contract Change: □ Marriage

□ Death

□ Divorce

□ Birth/Adoption

□ Other_____________________ Event Date _______________

SSN

Name (Last)

(First)

(MI)

Birth Date

Address (Street)

(Apt/Ste #)

Gender

Marital Status

(City)

(State)

(Zip)

(Phone Number)

□ Male □ Female

□ Single □ Married

□ Common Law

Medicare Enrolled? □ Yes □ No

Soc. Sec. Disabled? □ Yes □ No Medicare ID (HIC) No.

□ Part A □ Part B □ Part D Eff. Date:

B. Coverage Election – Please indicate the coverage you are choosing

□ Self

□ Spouse

□ Child(ren)

Plan Type_______________

Medical (if applicable):

□ Life

□ AD & D

□ STD

□ LTD

□ Self

□ Spouse

□ Child(ren)

Plan Type_______________

Dental (if applicable):

Vision (if applicable):

□ Self

□ Spouse

□ Child(ren)

Plan Type_______________

C. Employer – Please complete shaded section for applicant

Company Name

Applicant Occupation

Company Location

Class

Employer Signature

Date

Hire Date

Eff. Date

Employment Status: □ Full-Time □ Part-Time □ Retiree □ COBRA

Salary $

□ Monthly □ Annually

Please indicate plan if multiple plans are available: □ Health ______________ □ Dental ____________ □ Vision_____________

□ Employee Life

□ Employee AD&D

□ Employee Opt. Life

□ Dependent Life

□ Spouse Opt. Life

□ Employee STD

□ Employee LTD

D. Beneficiary Information

Birth Date

SSN

Relationship

Primary Beneficiary

Contingent Beneficiary

E. Dependents Enrolled

Birth Date

Social Security Number

Gender

Full-Time Student?

Soc. Sec. Disabled?

(First, MI, Last)

Medicare Enrolled?

Spouse

□ M □ F

□ Yes

□ No

□ Yes □ No

Dependent

□ M □ F

□ Yes

□ No

□ Yes

□ No

□ Yes □ No

Dependent

□ M □ F

□ Yes

□ No

□ Yes

□ No

□ Yes □ No

Dependent

□ M □ F

□ Yes

□ No

□ Yes

□ No

□ Yes □ No

Dependent

□ M □ F

□ Yes

□ No

□ Yes

□ No

□ Yes □ No

F. Other Coverage Information

G. Prior Coverage Information

If you, your spouse or anyone named on this application will

– Did you have health insurance in the last 63 days? If yes,

keep other hospital and/or medical coverage in addition to this coverage, please complete the

please complete the following section:

Name (First, MI, Last)

Name of Covered Person

Employer (if applicable)

Insurance Company/

HMO Name and Address

Policy No.

Contract Type: □ Single -Medical

Eff. Date:

Policy No.

Contract Type: □ Single -Medical

Eff. Date:

□ Family -Medical

End Date:

□ 2 person-Medical

H. Employee Waiver of Coverage

I, the undersigned, hereby certify that I have been given an opportunity to enroll in the group plan sponsored by my employer. After careful consideration, I have elected not to participate in the

following coverage(s). I further understand that should I decide to participate at a future date, I may have to furnish satisfactory evidence of insurability for myself and, if applicable, any eligible

dependents. If I am declining enrollment for myself or my dependents (including my spouse) because of other health insurance coverage, I understand that I may in the future be able to enroll

myself or my dependents in this plan, provided that I request enrollment within 30 days after my other coverage ends. In addition, if I have a new dependent as a result of marriage, birth, adoption,

or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

□ Employee Health

□ Employee Optional Life

□ Employee Dental

□ Spouse Optional Life

Employee Signature__________________________________________________________

□ Employee Vision

□ Dependent Health

Date______________________________________________________________________

□ Employee Life

□ Dependent Dental

□ Employee AD&D

□ Dependent Vision

Witness Signature ___________________________________________________________

□ Employee Weekly Indemnity (STD)

□ Dependent Life

□ Employee Long Term Disability (LTD)

□ Other ______________________

Date______________________________________________________________________

I. Employee Signature (Required for all available lines of coverage)

I HEREBY REQUEST to be covered and authorize deductions, if any, from my wages for my share of the cost of the benefits for which I am eligible, or may be entitled, under the coverage elected

on this form. I hereby represent that any disability indemnity coverage in force and applied for, with respect to myself, is less than 100% of my annual earnings and I further represent that I am not

presently disabled and I am performing all the duties of my occupation. (This statement applies to any disability coverage).

__________________________________________________________________

______________________________________

Signature__

Date

Revised 12/05

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