Enrollment Application/change/cancellation Request Form - Unitedhealthcare

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Enrollment Application/Change/Cancellation Request
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X
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Enroll
Address Change
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Cancel
Name Change
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Change
Date of Change____ /___ /____
To Be Completed By Employer
ATTENTION EMPLOYER REPRESENTATIVE: To ensure accurate processing of application, 1) please review all sections and confirm the
employee completed the appropriate information, 2) complete the information in this section and
3) provide your signature and
today’s date. If the employee is waiving coverage, do not submit the application but retain it for your records.
Company Name
Group #
Department #
07S1499
Mastery Learning Institute
Plan Variation
Reporting Code
Benefit Level/Class Code, if applicable
Medical ______
Vision ______
Medical ______ Vision ______
Life/AD&D ______ Suppl. Life
______
X
Dental
______
Life
______
Dental
______ Life
______
Spouse Life ______ Suppl. AD&D
______
UnitedHealthcare Overture Package ______ (A-S)
Dep. Life
______ Critical Illness ______
Cancellations: Last Date of Employment ___ /___ /___
X
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New Enrollment/Additions: (Check one)
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Requested Effective Date of Cancellation ___ /___ /___
Date of Hire ___ /___ /___
Requested Date of Coverage ___ /___ /___
Cancel all coverage
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New Hire
Status Change (PT to FT)
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Cancel all listed below – Section B
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Return from Leave/Layoff
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Reason: (check one)
Birth
Marriage
Adoption
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Death
Employee Terminated
Divorce
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Court ordered dependent
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Moved out of service area
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Other (describe) ________________________
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Dependent reached dependent max age
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COBRA/State Continuation start date _______ stop date________
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X
Other (describe)____________________________
Annual Open Enrollment Requested Effective Date of Enrollment ___ /__ /___
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x
x
Employee Type
Union
Non-union
Salaried
Hourly
Active
Retire Date ______
COBRA/State Cont.
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Signature ________________________________________________ Date ___________________
503-762-6061
Employer Position_____________________________ Phone Number________________________
Director of HR
A. Employee Information
Last Name
First Name
MI
Social Security Number
Home Phone
Work Phone
Address
Apt #
City
State
Zip Code
Email Address
Date of Birth
Sex
Physician* (First & Last Name) / Physician’s ID Number
Primary Care Dentist Number*
M
F
/
/
Race – Check all that apply (Optional)**
Marital Status
Single
Married
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Divorced
Widowed
Native Hawaiian/Pacific Islander
White
Other–Please specify ___________________________
*IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care Dentist
(PCD) selection.
**Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being and
not for eligibility or claim payment determination.
All references to Spouse include Domestic Partner
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company
Life Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
LG.EE.12.OR 9/12
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600-2376 10/12

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