Form Sg.ee.14.md - Employee Enrollment - 2013
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Employee Enrollment Form
□ UnitedHealthcare Insurance Company
□ Optimum Choice, Inc
□ Dental Benefit Providers of Illinois, Inc.
185 Asylum Street
800 King Farm Boulevard, Suite 600
Liberty 6, Suite 200
Hartford, CT 06103
Rockville, MD 20850
6200 Old Dobbin Lane
Columbia, MD 21045
□ UnitedHealthcare of the Mid-Atlantic, Inc.
□ MAMSI Life and Health Insurance Company
800 King Farm Boulevard, Suite 600
800 King Farm Boulevard, Suite 600
Rockville, MD 20850
Rockville, MD 20850
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
/
/
Group Name
Policy Number
Date of Hire
/
/
Employee Type
Reason for Application
New Group Plan
New Hire
(Check all that apply)
Life Event/Date_______
Annual
Active
COBRA
State Continuation
Position/Title
Status Change_______
Open
Start dt ____/____/____
Dependent Add/Delete
Enrollment
End dt____/____/____
Hours Worked per week
Change Name/Address
Late
Hourly
Salary
Part time to Full time
Enrollee
Union
Non-Union
Retired
Required only if Life, STD,
Waiving Coverage
Termination
Other ____________________________
Salary $_____________
Other _________________________
or LTD Plan based on salary
A. Employee Information
If you are waiving all coverage, please complete sections A and F.
Last Name
First Name
MI
Social Security Number
Address
Apt #
City
State
Zip Code
Home/Cell Phone
Date of Birth
Gender
Email Address
Work Phone
M
F
/
/
Marital Status
Language Preference, if not English
Single
Married
Divorced
Widowed
Primary Care Physician
1
Existing Patient?
Yes
No
Primary Care Dentist
2
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I – I___I___I
Existing Patient?
Yes
No
(1) For products requiring you to choose a Primary Care Physician (PCP), you must use the UnitedHealthcare directory of providers to choose
a PCP for yourself and each of your covered dependents. (2) Please see employer representative as some dental plans require a Primary Care
Dentist (PCD) selection. (3) For court ordered dependent, legal documentation must be attached. If a dependent does not reside with eligible
employee, please provide address on a separate sheet. (4) If you answered "Yes" for Disabled and the dependent child is 26 years of age or
older, unmarried, depends mainly on the subscriber for support, and is not able to be self-supporting because of mental or physical incapacity
that originated before the dependent attained the limiting age, please attach a medical certification of incapacitation.
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company or UnitedHealthcare of the Mid-Atlantic, Inc. or Optimum Choice, Inc. or MAMSI
Life and Health Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company or Dental Benefit Providers of Illinois, Inc.
Life, Short-Term Disability (STD), Long-Term Disability (LTD) and Accidental Death and Dismemberment (ADD) Insurance coverage provided by
UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
515-00492 10/13
SG.EE.14.MD 5/13
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