Form 400-2572-Enrollment Application-Change-Cancellation Request
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4Fully Insured Key Account Groups
Enrollment Application/Change/Cancellation Request
To speed enrollment process, please be thorough and fill out all sections that apply.
Enroll
Address Change
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If waiving medical coverage, please see Section E.
Cancel
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Name Change
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Change
Date of Change____ /___ /____
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A. Employee Information
First Na me
M.I.
Last Name
Social Security #/Employee ID #
Street Address
Apt. #
City
County
State
Zip
Country
Home Phone
Work Phone
How many hours do
Coverage Types
you work per week?
Medical
Dental
Vision
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Marital
Single
Divorced Sex
M Birthdate
Physician*
Physician’s ID No.
Are you a
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Status
Married
Widowed
F
current patient?
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B. Family Information
Yes
No
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Dependents (including domestic partners) to be enrolled, cancelled, changed: (Attach sheet if necessary)
Check
Are you
Last Name
First Name
M.I.
Cov. Physician
*
Full-Time
Sex Birthdate Relationship
**
appropriate
a Current
Student
Type Physician’s ID Number
***
Dependent/Domestic Partner Social Security No.
box
Patient?
Enroll
Yes
No
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YES
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Cancel
School Name:
D
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F
NO
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Change
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Enroll
Yes
No
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YES
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Cancel
School Name:
D
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F
NO
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Change
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Enroll
Yes
No
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YES
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Cancel
School Name:
D
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F
NO
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Change
SS# |
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*IMPORTANT: Please use the UnitedHealthcare directory of providers to choose a Primary Physician (Primary Care), for yourself and each of your covered
dependents for UnitedHealthcare Select and Select Plus only. **Your employer may have guidelines that require legal documentation from you for court
ordered dependents or other information in order to make other eligibility determinations. UnitedHealthcare does not require copies of legal documents.
Please see employer representative for more information about these qualifications. If dependent does not reside with eligible employee, please provide
address on separate sheet. ***Student verification will be requested for Over Age Dependents
C. Product Selection *(check all that apply)
upon presentment of a claim.
*Plan offerings are dependent upon employer election.
Medical Plan - If your employer offers you a choice of medical plans (i.e. Choice Plus POS, Options PPO),
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please write your medical plan selection here: _______________________ .
Dental Plan - If your employer offers you a choice of dental plans (i.e. Dental Options PPO, Dental Managed Indemnity)
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please write your dental plan selection here: _______________________ .
Comprehensive Vision Plan
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LIFE INSURANCE PRODUCTS
Life Beneficiary’s Full Name and Address
Salary $______________
Flat Amount $______________
wk
mo
yr
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Life/Accidental Death or Dismemberment
Supplemental Life
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Spouse/Domestic Partner Life Insurance
Suppl. Accidental Death and Dismemberment
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Relationship
Dependent Life Insurance
Critical Illness
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(This section must be completed)
D. Other Medical Coverage Information
On the day your coverage begins, will you, your spouse/domestic partner, or any of your dependents be covered under any other Medical Health plan
or policy including another UnitedHealthcare plan or Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
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Insurance Company Name (use extra paper if needed)
Coverage Start Date
Coverage Stop Date
Coverage type:
Group Policy
Individual Policy
Medicare/Medicaid
Other________________________________________________
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Is this coverage through your spouse’s/domestic Name, date of birth and Social Security # of policy holder
partner’s employer?
YES
NO If yes,
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please provide employer’s name
Employee’s relationship to policyholder
Names of family members with other continuing medical coverage (Including Medicare)
Medicare effective date
Reason for Medicare eligibility:
Medicare Claim #
Parts A&B
Over 65
Disabled
Kidney Disease
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continued on reverse
400-2572 08/06
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Parent category: Medical