Form Sg.ee.14.az - Employee Enrollment - 2013

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(DO NOT STAPLE)
Employee Enrollment Form
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
/
/
Plan Variation:
Medical □ UnitedHealthcare of Arizona, Inc. (HMO)
Check appropriate box(es) for coverage(s) selected.
Medical □ UnitedHealthcare Insurance Company (PPO/Insurance)
Medical □ All Savers Insurance Company (PPO/Insurance)
□ UnitedHealthcare Insurance Company
Dental
□ UnitedHealthcare Insurance Company
Vision
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance □ UnitedHealthcare Insurance Company
Group Name
Policy Number
Date of Hire
/
/
Employee Type
Reason for Application
(Check all that apply)
New Group Plan
New Hire
Life Event/Date_______
Annual
Active
COBRA
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 $_____________
or LTD Plan based on salary
Other _________________________
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
/
/
Do you use tobacco?
1
Marital Status
Single
Married
Divorced
Widowed
Yes
No
If yes, are you currently participating in a tobacco cessation program or
Language Preference, if not English
do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
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) Tobacco means all tobacco products, including, but not limited to, cigarettes, cigars, and chewing tobacco. You should only check the
“yes” box above if tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past 6 months
by someone of legal age to purchase tobacco in the state of residence. (2) For UnitedHealthcare Compass, Navigate, Select, Select Plus, and
other 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. (3) Please see employer representative as some dental plans require a Primary Care
Dentist (PCD) selection. (4) 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. (5) If you answered “Yes” for Disabled and the dependent child is 26 years of age or
older, unmarried, chiefly dependent upon subscriber for support and is not able to be self-supporting because of a physically or mentally
disabling injury, illness or condition, please attach a medical certification of disability.
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company or UnitedHealthcare of Arizona, Inc. or All Savers Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
390-7180 9/13
SG.EE.14.AZ 5/13
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