Fillable Form Gr-67834-20 - Aetna Enrollment Change Request Form (Page 2 of 3) in pdf

E. Other/Previous Coverage

If you have checked "Yes" to Other Dental Coverage (Section C), provide name(s) and policy number(s) of insurance carrier(s), dental plan, or other source; a copy of the insurance card(s), and

the start date(s) of coverage.

Is your Spouse/Civil Union Partner employed? If Yes, provide name and address of spouse's/civil union partner's employer.

Yes

PROOF OF PRIOR COVERAGE - IMPORTANT (Required)

Acceptable forms of proof are:

Dental:

Life:

Yes

1. Certificate of Creditable Coverage from prior carrier, or

Does anyone enrolling on this enrollment form have prior coverage other than with

2. Copy of ID card or most recent payroll stub showing dental

this employer? If Yes, provide their names, start and end dates of prior coverage.

coverage deduction, or

3. Copy of most recent dental premium bill from prior carrier.

Failure to provide Proof of Prior Coverage may subject you to the

12 month waiting period for coverage of Major and Orthodontic

Services on the Dental PPO plan options. You may request a

Certificate of Creditable Coverage from your prior carrier.

Proof of coverage and plan summary must accompany this enrollment form for possible

waiver of waiting period on Dental PPO plan options.

F. Dependent Information

Does any dependent listed in Section D live at a different address than the Employee? If "Yes," who and what address?

Yes

Explain the circumstances.

If any dependent's last name differs from yours, explain the circumstances.

G. Declination/Waiver of Coverage

- To be completed if life, disability, or dental coverage is declined or refused by an eligible employee and/or their

eligible family members.

1. Life Coverage Declined for:

Reason for Refusal - Please check all appropriate boxes.

(If applicable, please attach front/back of your coverage ID card(s).)

Employee

Spouse/Civil Union Partner

Other group coverage sponsored by my employer.

Children

Other group coverage sponsored by my spouse's/civil union partner's employer.

2. Disability Coverage Declined for:

Other group coverage by another organization.

Employee

Other (please explain):

3. Dental Coverage Declined for:

Please provide name of carrier and policy number.

Employee

Spouse/Civil Union Partner

Children

I was given the opportunity to enroll in these plans of group life, disability, and dental benefits offered by my employer and

insured by Aetna Life Insurance Company and Aetna Dental Inc.; however, I refuse the above coverage(s). I understand that if I

later wish to enroll for any of the coverage(s) refused, I will be required to submit an Enrollment

Request.

Please sign here ONLY if you are declining coverage for yourself or dependent(s).

Date (Month/Day/Year)

Employee Signature

Date (Month/Day/Year)

Witness Signature

If you have questions concerning the benefits and services provided by or excluded under this Agreement, contact a

H. Employee Signature

Member Services representative at 1-888-802-3862 before or after signing this form.

I represent that all the information supplied in this application is true and complete. I hereby agree to the conditions of enrollment

on the reverse side of the employee copy of this enrollment/change request. I authorize deductions from my earnings for any

required contributions.

Employee Signature - Required

E-Mail Address

Date (Month/Day/Year)

I. Employer Verification

- To Be Completed by Employer

Employer Signature - Required

Title

Date (Month/Day/Year)

GR-67834-20 (7-08)

Form Gr-67834-20 - Aetna Enrollment Change Request Form Page 2

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