Form Sb.eelng.10.mo - Employee Enrollment Form - 2010
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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
/
/
Group Name/Policy Number
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
Status Change_______
Open
Start dt ____/____/____
Hours Worked per week
Dependent Add/Delete
Enrollment
End dt____/____/____
Change Name/Address
Late
Hourly
Salary
Waiving Coverage
Enrollee
Salary $______ Required only if Life, STD, or LTD
Union
Non-Union
Retired
Termination
Plan based on salary
Other ____________________________
Other _________________________
A. Employee Information
If you are waiving all coverage, please complete sections A and G.
Last Name
First Name
MI
Social Security Number
Home/Cell Phone
Work Phone
Address
Apt #
City
State
Zip Code
Language preference, if not English
Used tobacco in the last
Date of Birth
Sex
Height
Weight
Email Address
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
Physician* (Name/ID#)
Sex Relationship***
Birthdate
Height
Weight
Used
Social Security Number
Primary Care Dentist** (Name/ID#)
Spouse
M
Yes
[/Domestic
F
No
Partner]
M
Yes
Dependent
F
No
M
Yes
Dependent
F
No
M
Yes
Dependent
F
No
M
Yes
Dependent
F
No
*Important: For UnitedHealthcare Navigate, Select, Select Plus, and other products requiring you to choose a Primary Care Physician, you
must use the UnitedHealthcare directory of providers to choose a Primary Care Physician for yourself and each of your covered dependents.
**Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. ***For court ordered dependent,
legal documentation must be attached. If dependent does not reside with eligible employee, please provide address on a separate sheet.
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company or UnitedHealthcare of the Midwest, Inc.
Dental coverage provided by UnitedHealthcare Insurance Company or UnitedHealthcare of the Midwest, Inc. or Dental Benefit Providers of Illinois, Inc.
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica
Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company
SB.EELNG.10.MO 6/10
350-3520 10/10
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Parent category: Medical