Form 400-2572-Enrollment Application-Change-Cancellation Request Page 2
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4Applicant Name ________________________
(This section must be completed if declining medical coverage)
E. Waiver of Medical Coverage
WAIVER
I decline to enroll for medical coverage for myself, my spouse/domestic partner, and my dependent children due to:
Existence of other health coverage
Spousal/Domestic Partner coverage
Other Reason (Explain) ______________________
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Check one of the above boxes, then read and sign.
I understand that if I and/or my dependents/domestic partner, if any, waive coverage and desire to participate in the plan at a later date, coverage may be
subject to treatment as a late enrollee and may apply at next open enrollment period. I further understand that if I decline enrollment for myself or my
dependents (including my spouse/domestic partner) because of other health coverage, I may in the future be able to enroll myself or my
dependents/domestic partner in this plan, provided that I request enrollment within 30 days after such coverage ends. In addition, if a new dependent
/domestic partnerrelationship forms as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my
dependent/domestic partner provided that I request enrollment within 30 days after such marriage, birth, adoption, or placement for adoption. I have read
and understand the “Important Information”located on the back of this form.
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Employee Signature__________________________________________________________
Date Signed_____________________________
(only sign if you are waiving coverage)
F.
Signature (Form must be signed)
I confirm that the information I have provided on this form is complete and accurate.
I understand that the health benefit plan that I have selected provides reimbursement for certain medical costs, which are more fully described in the
current Certificate of Coverage or Summary Plan Description. I understand there may be instances where treatment decisions made by my physician or
me or medical expenses which I have incurred may not be covered by my health benefit plan.
I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health products or
services that might be valuable to me and otherwise as permitted by law. I understand that you may combine that information with other information so
that it is no longer individually identifiable and use it for commercial and other purposes.
I acknowledge that I have received the “Important Information” statement which is included on the back of this form.
Date ___________ Employee Signature _______________________________ Spouse/Domestic Partner Signature _________________________
(if possible) and applicable
G. To Be Completed By Employer
ATTENTION EMPLOYER REPRESENTATIVE: To ensure accurate processing of application, 1) please review all sections and confirm employee
completed the appropriate information. 2) Complete section G. 3) Please provide your signature and today’s date.
Company Name
Group #
Department #
Plan Variation
Reporting Code
Benefit Level/Class Code, if applicable
Medical ______
Vision ______
Medical ______ Vision ______
Life/AD&D ______ Suppl. Life
______
Dental
______
Life
______
Dental
______ Life
______
Spouse Life______ Suppl. AD&D
______
UnitedHealthcare Overture Package ______ (A-S)
Dep. Life
______ Critical Illness ______
Last Date of Employment ___ /___ /___
Cancellations:
New Enrollment/Additions: (Check one)
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Requested Effective Date of Cancellation ___ /___ /___
Date of Hire ___ /___ /___
Requested Date of Coverage ___ /___ /___
Cancel all coverage
New Hire
Status Change (PT to FT)
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Cancel listed above – Section B
Return from Leave/Layoff
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Reason: (check one)
Birth
Marriage
Adoption (attach legal documentation)
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Death
Employee Terminated
Divorce
Court ordered dependent (attach documentation)
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Moved out of service area
Other (describe) ________________________
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Dependent reached student/dependent max age
COBRA/Continuation start date _______ stop date________
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Requested Effective Date of Enrollment ___ /___ /___
Annual Open Enrollment
Other (describe)______________________________
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Union
Non-union
Salaried
Hourly
Active
Retire Date _________
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Signature _____________________________________________________ Date ___________________________
Employer Position__________________________________________ Phone Number________________________
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