Change Request Form

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CHANGE
BMLL Billing #
Effective Date of Change
__ __ / __ __ / __ __
REQUEST FORM
Team #
THIS IS NOT AN APPLICATION FOR INSURANCE
Carrier Group #
□
□
Employer with 20 or more employees?
Name/Address Change
Beneficiary Change
Coverage Change
Cancel Coverage
Y
N
Employee
Social Security Number
Last Name
First Name
M.I.
Employer
Beneficiary Change:
I hereby revoke any current designation and change beneficiary to:
Name:
Relationship:
% of Benefit
Name:
Relationship:
% of Benefit
Name Change:
(Last, First, M.I.)
(Last, First, M.I.)
Previous Name:
New Name:
Address Change:
New Address:
Cancel Coverage:
All Coverages
Medical
Dental
Vision
COBRA/State Continuation
Other
If you are terminating employment, please mark the corresponding box(es) in the section below, enter the Last Day Worked and Termination Reason
Involuntary Termination
Voluntary Termination Termination Reason:
Last Day Worked: __ __ / __ __ / __ __
Coverage Change From (plan type) _________________ To ___________________
ALL COVERAGES
MEDICAL ONLY
DENTAL ONLY
VISION ONLY
OTHER
□
Life/AD&D
FROM
TO
FROM
TO
FROM
TO
FROM
TO
□
□
□
□
□ □
□ □
□
LTD
Employee Only
Employee Only
Employee Only
Employee Only
□
STD
□
□
□
□ □
□ □
□
Employee & Adult
Employee & Adult
Employee & Adult
Employee & Adult
□
Vol STD
□
□
□
□ □
□ □
□
Employee & Child(ren)
Employee & Child(ren)
Employee & Child(ren)
Employee & Child(ren)
□
Vol AD&D
□
□
□
□ □
□ □
□
Family
Family
Family
Family
□
Vol Dep Life
□
□
□
□
□
□
□
□
Over 65
Over 65
Over 65
Over 65
□
Vol Sup Life
□
□
□
□
□
□
□
□
Working
Retired
Working
Retired
Working
Retired
Working
Retired
□
Vol LTD
□
□
□
□
Medicare or
Medicare or
Medicare or
Medicare or
□
□
□
□
□
Vol Life
Complimentary to
Complimentary to
Complimentary to
Complimentary to
□
Other_________
Medicare
Medicare
Medicare
Medicare
(CareFirst-Individual only;
(CareFirst-Individual only;
(CareFirst-Individual only;
(CareFirst-Individual only;
and benefit coverage
and benefit coverage
and benefit coverage
and benefit coverage
From $ __________
only. Not eligible for HSA)
only. Not eligible for HSA)
only. Not eligible for HSA)
only. Not eligible for HSA)
To $_____________
QUALIFYING EVENT (REASON FOR CHANGE)
DATE: __ __ /__ __ / __ __
MEDICARE INFORMATION (please submit copy of Medicare card)
Medicare A Effective Date: __ __ / __ __ / __ __
□
□
Marriage/Divorce (provide date)
Loss of Coverage
□
□
Medicare B Effective Date: __ __ / __ __ / __ __
Medicare
Birth/Adoption
Medicare Policy Number:
(provide policy information)
□
Effective Date:
Overage Dependent
□
Death (provide date of death)
□
Open Enrollment
Carrier:
□
Other ________________
Medicare Policy #:
Termination Date:
Social
Birth
Sex
HMO & POS Plans:
Dis-
Existing
Student
Last,
Full First,
M.I.
Security
Date
Primary Care Physician/
abled
Patient
(Y/N)
Number
OBGyn Provider/Dental and #
(Y/N)
(Y/N)
(if required)
Emp
*Sp
*Chd
*Chd
: I hereby certify that I am the spouse, parent or legal guardian of the dependent(s) shown above.
CERTIFICATION
Any person who
knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false
.
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison
EMPLOYEE SIGNATURE ________________________________________________________________DATE_________________
EMPLOYER SIGNATURE/VERIFICATION___________________________________________________DATE_________________
P.O. Box 42827 Baltimore, MD 21284-2827
Fax: (410) 512-3984
3/10/09

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