Form Gbd-1540 Va - Group Retiree Health Insurance Plan Enrollment Form Page 2
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1
22.
If the answer to question 1 is yes, do you or your spouse, domestic partner, if enrolling intend to replace these
medical or health policies with this policy or certificate?
Retiree
Yes
No
Dependent Spouse
Yes
No Domestic Partner
Yes
No
If yes, for what reason are you (or your dependent spouse, domestic partner, child or parent, if enrolling) replacing
the coverage?
Additional Benefits
No change in benefits, but lower premiums
Fewer benefits and lower premiums
Other (please specify)
Integration with Medicare
3. Are you covered by Medicaid?
Retiree
Yes
No Dependent Spouse
Yes
No
Domestic Partner
Yes
No
Check Desired Coverage:
AGP-3844
Retiree
Dependent Spouse
Domestic Partner
Complete this form answering all questions. Please be sure to date and sign the form and return to:
Benistar Admin Services, Inc.
10 Tower Lane, First Floor
Avon, CT 06001
1-877-278-8787
I (we) understand and agree that any pre-existing conditions (conditions for which medical advice or treatment has been
received or recommended in the past six months) will not be covered until six consecutive months after the effective date
of coverage. I (we) understand that if I (we) plan on replacing any existing group medical coverage with this plan, then
this pre-existing condition limitation will be waived to the extent it was satisfied under the previous policy. I (we)
understand that coverage will become effective on the first day of the month following receipt by the Company of this
enrollment form and first premium payment.
Date:
Retiree Signature:
Date:
Dependent Spouse Signature:________________________________
(if enrolling)
Date:
Domestic Partner Signature: ________________________________
(if enrolling)
Form GBD-1540 VA
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