Form Sg.ee.14.az - Employee Enrollment - 2013 Page 2
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4Employee Name __________________________________________________________________________________________________________
B. Family/Dependent Information (continued)
List All Enrolling (Attach sheet if necessary)
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Spouse
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
/Domestic
in a tobacco cessation program or do you intend to join one?
Yes
No
Partner
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
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
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
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
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
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
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
Permanently disabled and age 26 or older
5
Yes
No
Please check the box for each coverage in which you or your dependents are enrolling.
If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount
C. Product Selection
selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability
(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.
Person
Medical
Dental
Vision
Basic Life/AD&D
Supp Life/AD&D
Employee
_____________
_____________
$_____________
$_____________
Spouse/Domestic Partner
_____________
_____________
$_____________
$_____________
Dependent
_____________
_____________
$_____________
$_____________
Person
STD
LTD
Employee
Life Insurance Beneficiary Full Name and Address
Relationship
(if applying for Life Insurance with UnitedHealthcare)
Primary
Secondary
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