Form Sb.ee.07.fl - Employee Enrollment Form - 2007
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Employee Enrollment Form
Group Name/Number
To speed the enrollment process, please be
thorough and fill out all sections that apply.
Group Name
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change
/
/
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
Hours Worked per week
Status Change_______
Open
Start dt __/__/__ End dt__/__/__
Dependent Add/Delete
Enrollment
Salary $______ Required only if Life Plan based on salary
Hourly
Salary
Other _______
Change Name/Address
Late
Union
Non-Union
Retired
A. Employee Information
Other ______________
Enrollee
Last Name
First Name
MI
Social Security Number
Home Phone
Work Phone
Address
Apt #
City
State
Zip Code
Email Address
Used tobacco in the last
Date of Birth
Sex
Height
Weight
Language preference, if not English
12 months?
Yes
No
M
F
/
/
Physician* (First & Last Name)/ ID #
Primary Care Dentist (First & Last Name)/ ID #
Marital Status
Single
Married
Divorced
Widowed
B. Family Information
List All Enrolling (Attach sheet if necessary)
Tobacco
Last Name
First Name MI
Full Time Physician* (Name/ID#)
Sex Relationship** Birthdate Height Weight
Student
Used
Social Security Number
Primary Care Dentist (Name/ID#)
M
Yes
Spouse
F
No
Yes
M
Yes
Dependent
No
F
No
Yes
M
Yes
Dependent
No
F
No
Yes
M
Yes
Dependent
No
F
No
*IMPORTANT: Please use the directory of providers to choose a Primary Physician (Primary Care) for yourself and each of your covered
dependents, for products requiring a Primary Physician designation only. **For court ordered dependents, legal documentation must be
attached. Please see employer representative for more information about the qualifications for student status. If dependent does not reside
with eligible employee, please provide address on a separate sheet.
C. Product Selection
Please check all that apply. Benefit offerings are dependent upon employer selection. Dual Option Plan Selected
Person
Medical
Dental
Vision
Life/Amount
Sup Life
Sup AD&D
STD
LTD
Medical
Dental
Employee
$______
Spouse
Dependents
Life Insurance Beneficiary’s Full Name and Address
Relationship
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc. or Neighborhood Health Partnership, Inc.
Dental coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc. or Neighborhood Health Partnership, Inc.
Life Insurance coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
Vision coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
SB.EE.07.FL 09/07
Page 1 of 3
213-2184 10/07
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Parent category: Medical