Enrollment/change/waiver Group Insurance Form
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1
2CLEAR FORM
enrollment/change/waiver
COBRA:
If individual is a continuee
Qualifying Event ____________________
group insurance form
P.O. Box 81889
Date of Event ______________________
Lincoln, NE 68501-1889
Policy and Div. # 010- ___________________ Cert. #____________________
800-659-2223 / Fax: 402-467-7338
Name and Address of Employer (Policyholder) ___________________________________________________________________________
to enroll
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Dental
Eye Care
To terminate all coverages
employee information
Marital Status
Single
Married
Social Security number ____________________________________
Dept. number ____________________________________________
Employee’s last name, fi rst name, MI ___________________________________________________________________________________
Date of birth _____________________________________________
Male
Female
Full time date of hire ______________________________________
Rehire: Rehire date ____________________________________
Occupation _________________________________________________________________________________________________________
Hours worked each week __________________________________
Are your earnings paid:
Hourly or
Salaried
Street address ___________________________________________
City _________________________ State______ ZIP____________
E-mail address (limit of 60 characters) __________________________________________________________________________________
Are you covered under another dental insurance plan? . . . . . . . . . . . . . . . . Employee:
Yes
No
Dependents:
Yes
No
Are you covered under another eye care insurance plan? . . . . . . . . . . . . . . . Employee:
Yes
No
Dependents:
Yes
No
dependent coverage information
List all eligible dependents to be added or deleted. (Employee must be enrolled to cover dependents)
print full legal name (last, fi rst. MI)
add
drop
relationship
sex
date of birth
social security number
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please sign
(employee/policyholder) The certifi cate provides dental and eye care benefi ts only. Review your certifi cate carefully.
As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct
premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case
of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate
to the best of my knowledge. The policyholder certifi es the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.
X
X
Employee Signature (do not print)
Date
Policyholder Signature (do not print)
Date
In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an applica-
tion for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefi t, is guilty of a crime and may be subject to fi nes and criminal penalties, including
imprisonment. In addition, insurance benefi ts may be denied if false information provided by an applicant is materially related to a claim. (State-specifi c statements on back.)
Effective Date
Class
Dep. Code
Employee late entrant date _________________________________
Dependent late entrant date ________________________________
to change
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Name change
New Name _______________________________________ Old Name____________________________________
Add dependent coverage
If due to marriage, what is the date of marriage? ____________________________________________________________________
If due to birth/adoption, what is the date of event?___________________________________________________________________
If due to loss of coverage, date and reason: ________________________________________________________________________
If other, the date of event and please explain: ______________________________________________________________________
Drop dependent coverage
Number of dependents still covered: ______ Effective date of drop: _________________________
Due to divorce
Due to death
Due to annual election period
Other (please explain) __________________________________________________________________________________________
to waive
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IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK
WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for:
myself (does not apply to TRUST policies)
spouse only
child(ren) only
spouse and child(ren)
because ___________________________________________________________________________________________________________
Name of insurance company and employer of dependent __________________________________________________________________
Should I desire to apply for this group insurance in the future, I realize that a “late entrant” penalty may be applied.
GR 875 Rev. 5-07
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113007L
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