Insurance Change Form
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Rev. August 2014
Insurance Change Form
Please use black ink only, when completing this form.
Policy No. 5050001
Company Name: ___________________________________
Acct. Number __ __ __ __
New Employees: Please do not use this form. Mail or fax completed Insurance Enrollment Forms prior to the coverage effective date.
This form is to be used for changes to existing, covered employees only. Please use Enrollment Forms for any new employees.
Cancellations
Name
Social Security Number
Effective Date
Reason (terminated, retired, leave, etc.)
Employee Changes
Name
Social Security Number
Effective Date
Reason (reinstate, address/salary update, name change)
Dependent additions/deletions
Employee Name:
Last Name
First Name
Middle Initial
Relationship /
Sex
Date of Birth
Effective Date
Add / Delete
Reason
(e.g. birthday, marriage)
Last Name
First Name
Middle Initial
Relationship /
Sex
Date of Birth
Effective Date
Add / Delete
Reason
(e.g. birthday, marriage)
Employee Name:
Last Name
First Name
Middle Initial
Relationship /
Sex
Date of Birth
Effective Date
Add / Delete
Reason
(e.g. birthday, marriage)
Last Name
First Name
Middle Initial
Relationship /
Sex
Date of Birth
Effective Date
Add / Delete
Reason
(e.g. birthday, marriage)
Remarks
Form Cannot be Processed without Authorizing Signature
Signature of Authorized Person: ___________________________________________
Date: _________________________
Mail completed forms with your premium payment, or email
to your
Account Rep.
Questions:
Changes received after the 15th of the month may not be reflected on your next statement.
phone 800-842-6513
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Parent category: Legal