Form Sb.ee.10.va - Employee Enrollment Form - 2010
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Employee Enrollment Form
To speed the enrollment process, please be thorough and fill out all sections that apply.
UnitedHealthcare of the Mid-Atlantic, Inc.
X
UnitedHealthcare of the Mid-Atlantic, Inc. (“The Company”)
800 King Farm Boulevard
UnitedHealthcare Plan of the River Valley, Inc. (“The Company”)
Rockville, MD 20850
UnitedHealthcare Insurance Company (“The Company”)
UnitedHealthcare Plan of the River Valley, Inc.
Unimerica Insurance Company (“The Company”)
1300 River Drive, Suite 200
Optimum Choice, Inc. (“The Company”)
Moline, IL 61265
MD-Individual Practice Association, Inc. (“The Company”)
UnitedHealthcare Insurance Company
185 Asylum Street
Hartford, CT 06103
Unimerica Insurance Company
10701 West Research Drive
Milwaukee, WI 53226
Optimum Choice, Inc.
800 King Farm Boulevard
Rockville, MD 20850
MD-Individual Practice Association, Inc.
800 King Farm Boulevard
Rockville, MD 20850
Group Name
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change
/
/
Group Name/Policy Number
Date of Hire
/
/
Employee Type
Reason for Application
New Group Plan
New Hire
(Check all that apply)
Position/Title
Life Event/Date_______
Annual
Active
COBRA
State Continuation
Status Change_______
Open
Start dt ____/____/____
Hours Worked per week
Dependent Add/Delete
Enrollment
End dt____/____/____
Change Name/Address
Late
Hourly
Salary
Waiving Coverage
Enrollee
Union
Non-Union
Retired
Termination
Other ____________________________
Other _________________________
A. Employee Information
Last Name
First Name
MI
Social Security Number
Home/Cell Phone
Work Phone
Address
Apt #
City
State
Zip Code
Language preference, if not English
Used tobacco in the last
Date of Birth
Sex
Height
Weight
Email Address
12 months?
Yes
No
M
F
/
/
Physician* (First & Last Name)/ ID #
Primary Care Dentist** (First & Last Name)/ ID #
Marital Status
Single
Married
Not necessary to fill in
Not necessary to fill in
Divorced
Widowed
Medical coverage provided by UnitedHealthcare of the Mid-Atlantic, Inc., UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance
Company, Optimum Choice, Inc., or MD-Individual Practice Association, Inc.
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance
Company
Vision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company
SB.EE.10.VA 6/10
445-4032 1/11
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Parent category: Medical