Form Sg.ee.14.tx - Employee Enrollment - 2013
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Employee Enrollment Form
UnitedHealthcare Insurance Company
UnitedHealthcare of Texas, Inc.
To speed the enrollment process, please be thorough and fill out all sections that apply.
National Pacific Dental, Inc.
Group Name
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change
/
/
Group Name
Policy Number
Texas Rural Water Association
02H7058
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
Waiving Coverage
Termination
Required only if Life, STD,
Other ____________________________
Salary $_____________
Other _________________________
or LTD Plan based on salary
*Does not apply to health benefits
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
Sex
Email Address
Work Phone
M
F
/
/
Do you use tobacco?
1
Yes
No
Marital Status
Single
Married
Divorced
Widowed
If yes, are you currently participating in a tobacco cessation program or
do you intend to join one?
Language Preference, if not English
Yes
No
Do you have a disability affecting your ability to communicate or read?
Yes
No
Primary Care Physician
2
, Obstetrician or Gynecologist 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
HMO female enrollees are not required to select an obstetrician or gynecologist. Obstetrical or gynecological care can be received from her
primary care physician, primary care provider or an obstetrician or gynecologist.
List All Enrolling (Attach sheet if necessary)
B. Family Information
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 in a tobacco cessation program or
/Domestic
do you intend to join one?
Partner
Yes
No
Primary Care Physician
2
, Obstetrician or Gynecologist 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 Health Maintenance Organization (HMO) products, including 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 HMO 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.
275-7354 1/14
SG.EE.14.TX 5/13
Page 1 of 4
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