Form Gg-013374-L-D-Di-V - Enrollment/change Form - Life/dental/disability/vision - 2005

ADVERTISEMENT

ENROLLMENT/CHANGE FORM
Please Print clearly and in Black or Blue ink
Please Print in Capital Letters only
LIFE/DENTAL/DISABILITY/VISION
*
*
Planholder Name (Company Name)
Group Plan Number
Division Class
PLEASE CHECK APPROPRIATE BOX
Initial Enrollment/Refusal of Coverage
Add Employee/Dependents
Drop/Refuse Coverage
Information Change
(Complete Sections 1, 3, 4, 6)
(Complete Sections 1, 3, 5, 6)
(Complete Sections 2, 4, 6)
(Complete Section 6)
S
S
(The date of withdrawal cannot be prior to the date this form is completed and signed.)
Add Employee
Add Spouse
Add Children
E
E
Drop Employee (Complete Section 4)
Drop Dependents (Complete Section 4)
Newborn
C
C
Termination of Employment *
New Hire
Marriage Date _____ /_____ /_____
T
T
Last Day of Coverage _____ /_____ /_____
Previously refused this coverage
I
I
Retirement *
Previously refused this coverage
Previously refused this coverage
Adoption Date _____ /_____ /_____
O
O
*Last Day Worked _____ /_____ /_____
Loss of Other Coverage
Loss of Other Coverage
Loss of Other Coverage
N
N
*Last Day of Coverage _____ /_____ /_____
(Complete Section 5 if applicable)
(Complete Section 5 if applicable)
(Complete Section 5 if applicable)
Other __________________________________________________________________
1
2
SELECT COVERAGE(S):
SELECT COVERAGE OPTIONS:
REFUSE/DROP COVERAGE(S):
Dependents cannot be
Choose only one
LOSS OF OTHER COVERAGE:
Life
enrolled for coverage refused by the employee.
option for each coverage.
Spouse
Child(ren)
Employee
S
S
S
I and/or my dependents were previously covered under
AD&D
Life
Employee
Employee
Spouse
Child(ren)
Family (includes EE, Sp, Ch)
E
E
E
another group plan. Loss of coverage was due to:
Dental
Employee
Spouse
Child(ren)
C
AD&D
Employee
Family (includes EE, Sp, Ch)
C
C
Vision
Spouse
Child(ren)
Employee
T
T
T
Termination of Employment ______ /______ /______
Dental
Dental
Employee
Spouse
Child(ren)
Indemnity
PPO
Buy-Up
Pre-Paid *
Long Term Disability
I
I
I
* Complete Pre-Paid Office # in Section 6
Vision
Employee
Spouse
Child(ren)
O
Short Term Disability
O
O
Divorce
______ /______ /______
N
N
N
LTD
Buy-Up
I have been offered the above coverages and wish
Long Term Disability
(if applicable choose option)
to refuse/drop enrollment for the following reasons:
Death of Spouse
______ /______ /______
Flex AbilityGuard $____ (up to 50% of salary)
3
4
5
Covered under another insurance plan
Short Term Disability
(if applicable choose option)
STD
Buy-Up
Other ___________________________________
______ /______ /______
Term./Expiration of Coverage
Flex AbilityGuard $____ (up to 50% of salary)
(additional information may be required)
Pre-Paid Office #
Last
First
MI Sex
Birth Date
Social Security Number
(MM DD YYYY)
(See directory)
Add Drop
Employee
M F
-
-
-
-
Name
Street address
City
State ZIP
Marital Status:
Single
Married
Divorced
Legally Separated
Widowed
S
Home Phone: (
)
-
E
Are you: Actively at work
Occupation/Job Title:
Retired
Other _________ (additional information may be required)
C
Annual Salary (nearest dollar):
Date of Full Time Hire
Number of hours worked per week:
(MM DD YYYY):
-
-
T
,
,
I
Pre-Paid Office #
Last
First
MI Sex
Birth Date
Social Security Number
Student
(MM DD YYYY)
(See directory)
Add Drop
O
Spouse
M F
-
-
-
-
N
Name
Child
M F Y N
-
-
-
-
6
Name
Child
M F Y N
-
-
-
-
Name
Child
M F Y N
-
-
-
-
Name
Child
M F Y N
-
-
-
-
Name
A)
Have you included stepchildren?
Yes
No Are they dependent upon you for support and maintenance? Yes
No
B)
Is this your first eligible child?
Yes
No
If "no," please list all eligible children above.
Beneficiary Designation: (Include full proper name and relationship)
Name:
Relationship:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of
The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form which I have read and understand.
insurance fraud.
-
-
Signature: __________________________________________________________________
Date
(MM DD YYYY)
GG-013374-L-D-DI-V 2/05

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2