Employee Supplemental Enrollment Form - Unitedhealthcare
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Employee Supplemental Enrollment Form
Dental/Vision/Life/AD&D/STD/LTD
Group Name/Number
To speed the enrollment process, please be
thorough and fill out all sections that apply.
Group Name
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change
/
/
Date of Hire
/
/
Employee Type
Reason for Application
New Group Plan
New Hire
(Check all that apply)
Position/Title
Life Event/Date_______
Annual
Active
COBRA/State Continuation
Hours Worked per week
Status Change_______
Open
Start dt __/__/__ End dt__/__/__
Dependent Add/Delete
Enrollment
Salary $______ Required only if Life Plan based on salary
Hourly
Salary
Other _______
Change Name/Address
Late
Union
Non-Union
Retired
A. Employee Information
Other ______________
Enrollee
Last Name
First Name
MI
Social Security Number
Home Phone
Work Phone
Address
Apt #
City
State
Zip Code
Email Address
Date of Birth
Sex
Language preference, if not English
M
F
/
/
Primary Care Dentist (First & Last Name)/ ID #
Marital Status
Single
Married
Divorced
Widowed
B. Family Information
List All Enrolling (Attach sheet if necessary)
Last Name
First Name MI
Full Time Financially
Disabled
Student Dependent
Sex Relationship Birthdate
Primary Care Dentist (Name/ID#)
Social Security Number
(Over Age 19,
(Over Age 19,
(Over
Under 24)
Under 24)
Age 19)
M
Spouse
F
Yes
Yes
Yes
M
Dependent
No
No
No
F
Yes
Yes
Yes
M
Dependent
No
No
No
F
Yes
Yes
Yes
M
Dependent
No
No
No
F
For court ordered dependent, legal documentation must be attached. Please see employer representative for more information about the
qualifications for full-time student status. If dependent does not reside with eligible employee, please provide address on a separate sheet.
C. Product Selection
Please check all that apply. Benefit offerings are dependent upon employer selection. Dual Option Plan Selected
Person
Dental
Vision
Life/Amount
Sup Life
Sup AD&D
STD
LTD
Dental
Employee
$______
Spouse
Dependents
Life Insurance Beneficiary’s Full Name and Address
Relationship
Coverage Provided by “UnitedHealthcare and Affiliates”:
Dental coverage provided by United HealthCare Insurance Company [or United HealthCare of XXX]
Life Insurance coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
Vision coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
SB.EEANC.08.CO 12/08
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[XXX-XXXX 9/09]
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