Form Sg.ee.14.mo - Employee Enrollment - 2014 Page 2
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4Employee Name __________________________________________________________________________________________________________
B. Family/Dependent Information (continued)
List All Enrolling (Attach sheet if necessary)
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I – I___I___I
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I – I___I___I
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I – I___I___I
Permanently disabled and age 26 or older
5
Yes
No
Last Name
First Name
MI
Sex
Date of Birth
Relationship
4
M
F
/
/
Social Security Number
Do you use tobacco?
1
Yes
No If yes, are you currently participating
Dependent
in a tobacco cessation program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Existing Patient?
Yes
No
Physician First & Last Name _________________________________
Dentist First & Last Name __________________________________
Address _________________________________________________
ID# ___________________________________________________
ID# ___I___I___I___I___I___I___I___I___I___I___I – I___I___I
Permanently disabled and age 26 or older
5
Yes
No
Please check the box for each coverage in which you or your dependents are enrolling.
If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount
C. Product Selection
selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability
(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.
Person
Medical
Dental
Vision
Basic Life/AD&D
Supp Life/AD&D
STD
LTD
Employee
_____________
_____________
$_____________
$_____________
Spouse
_____________
_____________
$_____________
$_____________
Dependent
_____________
_____________
$_____________
$_____________
This health benefit plan does not include coverage for elective abortions.
Exclusive Provider Organization Notice
This notice applies to managed care health benefit plans that require all health care services be delivered by providers participating in our network.
With the exception of emergency medical conditions, life-threatening conditions, disabling degenerative disease treatments, and certain mental health
benefits, this health benefit plan covers only services received by providers participating in our network.
You can opt-out of this health benefit plan and be enrolled in a health benefit plan which includes out-of-network benefits by checking the box on
the right.
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