Employer Enrollment Form
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4Employer Enrollment Form
KENTUCKY
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this Employer Enrollment Form as
“Humana”, “We”, “Us”, or “Our”.
• Humana Health Plan, Inc., 321 West Main Street, Louisville, KY 40202 • Humana Insurance Company of Kentucky, 500 West Main Street,
Louisville, KY 40202 • The Dental Concern, Inc., 500 West Main Street, Louisville, KY 40202
For PPO, HMO, or POS Medical plans, coverage is provided by Humana Health Plan, Inc., a Health Maintenance Organization. For Indemnity
Medical plans, insurance coverage is provided or administered by Humana Insurance Company of Kentucky. For Dental, insurance coverage is
provided or administered by The Dental Concern, Inc. Vision plans insured or administered by The Dental Concern, Inc.
Association Name and Group number:
1. EMPLOYER INFORMATION -
Please type or print clearly in black ink
KY Assoc Builders & Contr 28300
Employer name:
Requested effective date
_ _ / _ _ / _ _ _ _
Situs location street address:
City:
State:
ZIP code:
County:
Date company established
Federal Tax ID:
Nature of business/SIC code:
Phone number:
(MM/DD/YYYY):
Benefit Administrator/management contact name:
Phone number:
Email address:
Billing contact name:
Billing address (N/A if same as street address):
City:
State:
ZIP code:
Phone number:
Email address:
Are separate divisions/classes required for billing or reporting? £ No £ Yes
X
If yes, please explain. Attach additional signed and dated sheets, if necessary.
2. ELIGIBILITY REQUIREMENTS
Average total number
This means the average number of employees for the preceding calendar year. An employee is typically any
of employees
person for which the company issues a W-2, regardless of full-time, part-time or seasonal status or whether
or not they have medical coverage.
Average number of
For all employees included in the average total number of employees (above), calculate the average
full-time equivalent
number of full-time equivalents for the preceding calendar year. The monthly full-time equivalents are
employees
calculated as follows:
• number of full-time employees (who worked 30 hours or more per week on average); plus
• total number of hours worked by part-time employees during the month capped at 120 hours, divided
by 120.
Medical
Dental
Vision
Eligible employee count
(including those employees
who waive coverage):
Are you offering coverage to retirees (Non-Community Rated Medical, Dental and Vision)? £ No £ Yes
Required age (minimum 50):
Minimum years of service:
0
Medical:
Dental:
Vision:
Number of retirees to be covered:
0
0
Does this company have any subsidiaries or affiliates, or are there any other associated entities that are eligible to file a federal or state
combined tax return? £ No £ Yes If yes, enter information below:
Company name
Total employees
Probationary waiting period for eligible employees: £ 0 days £ 30 days £ 60 days £ 90 days £ Other: ______
If you prefer months, please select “Other” and specify the number of months.
Medical probationary waiting period must not exceed 90 days. HMO plans requiring referrals must not exceed 60 days.
KY-52669 1/2016
1
Rev. 2/2016
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