Form Gr-67834-20 - Aetna Enrollment Change Request Form

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New Jersey Small Group Life, Disability, and Dental
Enrollment/Change Request
Aetna Dental Inc. /Aetna Life Insurance Company
Employer Group Information -
To Be Completed by Employer:
(Please complete if a current Aetna customer.)
Group Name
Suffix
Account
Plan No.
Life - Control
Disability - Control
Suffix
Account
Plan No.
Dental - Control
Suffix
Account
Plan No.
A. Type of Activity
- To Be Completed by Employer
Refer to instructions on back before completing this form. Print clearly.
1. Enrollment
2. Change -
3. Remove or Terminate -
Date of Event
Effective Date
Check all that apply.
Check all that apply.
/
/
/
/
New Enrollee/Subscriber
Add Spouse
Remove Spouse*
/
/
/
/
Add Civil Union Partner
Remove Civil Union Partner*
Effective Date
/
/
/
/
Remove Dependent Child*
/
/
Add Dependent Child
/
/
/
/
Name Change
Employee Withdrawal/Termination
Date of Hire
/
/
NOTE: Employee must be enrolled for spouse/dependent(s) to have coverage.
Change Plan
/
/
/
/
Other
* Please complete Add/Change/Remove and Name columns in Section D.
B. Employee Information
- Complete Sections B - H.
Social Security Number
Last Name, First Name, M.I.
Home Telephone
(
)
Home Address
Apt. No.
City, State
ZIP Code
Date of Employment
Hours Worked
Employer Name
Work Telephone
Per Week
(
)
Work Address
City, State
ZIP Code
C. Plan Option
- Your selection must be offered by your employer.
1. Life and Disability
2. Dental
- To enroll, enter plan number and name of your election below.
Basic Life/AD&D Ultra
TM
Contributory Plans: Option Number:
Plan Option Name:
Optional Dependent Life
Voluntary Plans: Option Number:
Plan Option Name:
Life & Disability Packaged Plan
If your employer has 25 or more employees and you are offered Option 2 - DMO, you must also be
Other
offered one of the PPO plans. If your employer has 3 or more employees and you are offered Voluntary
Beneficiary Designation - Full Name (First, Middle, Last)
Option V2 - DMO, you must also be offered Voluntary Option V4 - PPO Max.
Beneficiary Social Security Number
Relationship to Employee
Before today, were you covered under this employer's dental plan?
Yes
No
D. Individuals Covered
- List individuals whom you are enrolling or adding/changing/removing for Life and/or Dental coverage. Attach proof if full-time student.
Please Note: Disability is only available for the employee.
Coverage
Last Name, First Name, M.I.
Sex
Birthdate
Social Security
Dentist Office
Election
Number
ID Number
(A)dd
(if applicable)
(C)hange
(R)emove
M
F
MM
DD
YYYY
Yes
Yes
Yes
Yes
Life/Dis
Employee
/
/
Dental
Spouse/
Life
/
/
Civil Union
N/A
Dental
Partner
Life
Child
/
/
N/A
Dental
Life
Child
/
/
N/A
Dental
Life
Child
/
/
N/A
Dental
1
SGB GR-67834-20 (7-08) R-POD A

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