Enrollment Application And Change Of Information Form
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1
2Enrollment Application and Change of Information Form
Enrolled online _______________________
Date _____________________
* Group/Employer
______________________________________________
*Group
ID:__________________
*Subgroup ID or
Name:___________________________
*Class:__________________
* Coverage:
Type of Application
Changes
Terminate Dependent(s) - List Dependent(s) being
Address Change
Dental Coverage
terminated in dependent section, date and reason.
New Enrollment or Rehire
Name Change
New Name:____________________
Termination Date:_____________
Effective Date: _____________________
Effective Date:__________________
Old Name:_____________________
Reason:_____________________
Open Enrollment
Add Members(s) - List Members(s) to add in member section and qualifying event date*.
COBRA
Newborn Birth Date:__________
Court Appointed Guardian
*Member adds require a qualifying event date
COBRA (not for current employees)
Adoption Date:______________
Date:________________
unless added during open enrollment.
Marriage Date:______________
Loss of Group Coverage
COBRA Qualifying Events:
Date:__________________
(marriage certificate required with enrollment)
Divorce
End of employment
Domestic Partnership Affadavit
Returned to Full-Time Student Status
Date: _______________________
Date: ______________________
Reduction in hours
Loss of dependent child status
Only if applicable to your plan (Domestic Partner Affadavit
Other ____________
Event Date:_________________
Please complete this form and sign on the back. Please type or print legibly in ink. Thank you!
required with enrollment)
* Date of Employment
* Employee First Name
M.I.
* Last
* Birth date
* Employee Social Security #
mm/dd/yy
* Employee Mailing Address
* City
* State
* Zip
Home Phone Number
(
)
* Relationship code: SP=Spouse, DP=Domestic Partner
* Name
Is this dependent a full-time
* Birth date
* Gender
* Relationship
If yes, school name
First
M.I.
* Last
college student?
M
F
Self
Spouse
DP
Child
Child
Child
Child
Ward
Other Insurance (Coordination of Benefits)
Will employee or any dependents have other insurance?
Dental
No Other Dental Insurance
OVER
801283 (02/09)
* Enrollment will be delayed if fields noted in red or with an asterisk are not filled out.
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Parent category: Business