Enrollment Application

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Enrollment Application
Group
Cobra
Association and Colleges
PO Box 363628 SJ PR 00936-3628 • Tel. 787-774-6060
FILL OUT THE FORM ON BOTH SIDES / INCOMPLETE APPLICATIONS WILL BE RETURNED WITHOUT PROCESSING
PLEASE PRINT / Please read the instructions on the back of this form before filling out the information.
Effective Date
Tipo
Group Number
Social Security Number or Medicare Number
Section Number
Month
Day
Year
Name of the Group/Section
This contract is:
NEW
CONVERSION
RENEWAL
INDIVIDUAL
FAMILY
COUPLE
Main Policyholder
Marital Status Gender
Last Name, Name, Middle Initial
Date of Birth
F
M
Month
Day
Year
Mailing Address
Employee Number according to paycheck
Driver’s License or Member number (in case of associations or colleges)
City
Country/State
Zip Code
E-mail Address
Position
Date of Job
Fax
Mobile
Month Day
Year
Home
Office
(
)
(
)
(
)
(
)
Optional benefits requested for you and your direct dependents
BASIC
Direct Dependents
Social Security Number or Medicare Number
Last Name, Name, Initial (Spouse and Children)
Date Of Birth
Gender
Code
F M
Parent Depend
Month Day Year
Relationship
Relationship
Relationship
Relationship
Relationship
Optional Dependent
Relationship Date Of Birth
Social Security Number or Medicare Number
Last Name, Name, Initial
Marital Status
Gender
Month Day Year
F M
Code
Parent
Depend
BASIC
Gender Social Security Number or Medicare Number
Last Name, Name, Initial
Relationship Date Of Birth
Marital Status
F M
Month Day Year
Code
Parent
Depend
BASIC
Coordination
If you or your spouse has another Health Plan indicate:
COB Number
COB Code
Name of main policyholder of the other plan
Policy Number
Company
Effective Date
Code
Month
Day
Year
Parent Depend
BASIC
Conversion
Prior Triple-S Contract number if this contract is a conversion
Last Payment
Conversion
Use
Unpaid
Leave
Month
Year
Month
Year
COM.
SUPS.
SSS
COBRA
COBRA
Resignation
Lay-off
Retirement
Employee enrolled in Medicare
Death
Divorce
Reason for requesting “COBRA”
Not elegible as dependent
Other ____________________________________________________
Date of Notice to Employer
COBRA effective date
Date of Event
Requested by:
Day
Day
Day
Month
Year
Month
Year
Month
Year
Employer
Direct Dependent
SIGNATURE OF APPLICANT
SIGNATURE GROUP ADMINISTRATOR
DATE (MONTH / DAY / YEAR)
Modelo PG Rev. 7/2010

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