Enrollment/change Form
ADVERTISEMENT
1
2Enrollment/Change Form
Group Accident Insurance provided by:
UNITEDHEALTHCARE INSURANCE COMPANY
185 Asylum St.
Hartford, CT 06103-3408
Basic Life and Basic AD&D Insurance, Supplemental Life and Supplemental AD&D
Insurance, Short Term Disability Insurance, Long Term Disability Insurance provided by:
UNIMERICA LIFE INSURANCE COMPANY OF CALIFORNIA
10701 West Research Drive
Milwaukee, WI 53226
TO BE COMPLETED BY EMPLOYER
Employer Name:
Policy Number:
Employer Authorization:
Date of Hire: _____/_____/________
Class:
Plan Variation/Reporting Code:
Plan:
Requested Effective Date of Coverage / Date of Change: _____/_____/________
Enroll
Cancel
Change
New Group Plan
New Hire
Annual Open Enrollment
Address Change
Reason:
Name Change
Employee Terminated
Marriage
Domestic Partnership*
(Check the
Dissolution Domestic
Divorce
Death
Birth
Appropriate
Adoption/Legal Custody
Court Ordered Dependent
Cobra/State Continuation
Boxes)
Other:
Start Date ___/___/___ End Date ___/___/___
EMPLOYEE INFORMATION
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Employer Assigned ID#
Date of Birth: _____/_____/________
First
Name:
Last Name:
Middle Initial:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Email Address:
Annual Salary
Sex:
Male
Female
Marital Status:
Single
Married
Domestic Partner *
Employment Status: I am Actively at Work and have worked at my usual/required place of business for the past 30 days?
Yes
No
I am scheduled to work _____ hours per week and have worked those hours for the past 30 days?
Yes
No
Employee Type (Check all that apply):
Active
Hourly
Salary
Union
Non-union
Retired
Other
BENEFIT ELECTIONS
Person
Basic Life
Basic AD&D
Supplemental Life
Supplemental AD&D
Employee
$________
$________
$_________
$_________
Spouse (or Dom.Part*)
$________
$_________
$_________
Dependent
$________
$_________
$_________
Waive
Waive
Waive
Waive
(if applicable)
(if applicable)
Have you used tobacco of any kind
in the past 12 months?
Yes
No
Spouse?
Yes
No
Life Insurance Beneficiary(ies) Full Name and Address
Relationship
Person
STD
LTD
Employee
________
_________
Buy-up
Buy-up
1) ______________________________
Primary
Secondary
Waive
Waive
(if applicable)
(if applicable)
2)_______________________________
Primary
Secondary
Person
Accident Insurance
Employee
Base Benefit
Base + Enhanced
Spouse (or Dom.Part*)
Dependent
Additional Benefits (if applicable)
Additional AD&D
Waive
Outpatient Medical Expense
(if applicable)
Catastrophic Injury
SPECALL-ENROLL-ER-CA (08/2012)
Page 1
400-5800 8/12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical