Unitedhealthcare Employee Enrollment Form
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1
2To speed the enrollment process,
Group Name/Number
please be thorough and fill out
all sections that apply.
Group Name
To Be Completed by Employer
New
Dependent Add/Delete
Change Name/Address
Cancel
Date of Change
Reason for Application
Group Specifics
Product Selection
Employee Type
New Group Plan
Health
Yes
No
Active
Yes
No
Position/Title
Annual Open Enrollment
Life
Yes
No
COBRA./St Cont
Yes
No
Hours Worked
New Hire
$______________
Hourly
Yes
No
Status Change _____________
Plan Selected
Dep Life
Yes
No
Salary
Yes
No
Life event/date _____________
Medical_____________________
Dental
Yes
No
Union
Yes
No
Other ____________________
Dental______________________
Vision
Yes
No
Non-Union
Yes
No
Other
_______________
DATE OF HIRE ________________
Other ___________________
A. Employee Information
First Name
MI
Last Name
Social Security Number
Home Phone
Work Phone
Address
Apt #
City
State
Zip
Email Address
Language preference for receiving plan information:
English
Spanish
Other __________________________________________
B. Family Information
List All Enrolling
(Attach sheet if necessary)
Marital Status
Single
Married
Last Name
First Name MI Sex Relationship** Birthdate
Height
Weight
Full Time Physician*(First and Last Name)
Student
M
Employee
Self
F
Spouse/Dom.
M
Partner
F
Yes
M
No
F
*IMPORTANT: Please use the UnitedHealthcare directory of providers to choose a Primary Physician (Primary Care) for yourself and each of
your covered dependents, for UnitedHealthcare Select and Select Plus only. **For court ordered dependent, legal documentation must be
attached. Please see employer representative for more information about the qualifications for full-time student status. If dependent does not
reside with eligible employee, please provide address on a separate sheet.
C. Product Selection
(Please check all that apply)*
Dual Option Plan
Person
Medical
Life
Sup Life
Sup AD&D
Dental
Vision
STD
LTD
Number
Employee
$
$
$
Spouse/Dom. Partner
$
Dependents
$
*Benefit offerings are dependent upon
Life Beneficiary’s Full Name and Address
Relationship
employer election
D. Other Coverage Information
Yes
No
Has anyone on this application been covered with health benefits,
List dates covered
List all family members covered
including coverage with UnitedHealthcare within the past 2 years?
Yes
No
Are you or any of your dependents covered by Medicare?
Reason
Over 65
Disabled
Covered by Part
Kidney Disease
A
B
If yes, Name of Medicare Beneficiary
Date Medicare became effective
Claim Number
Declining coverage due to existence of other coverage:
I understand that by waiving coverage at this time, I will
E. Waiver of Coverage
not be allowed to participate unless I experience a life
Spouse’s /Dom. Partner Employer’s Plan
I decline coverage for:
change event, at the next open enrollment period or as a
Individual Plan
Covered by Medicare
Medicaid
Myself and all dependents
late enrollee, if applicable. I also understand that
COBRA from Prior Employer
VA Eligibility
Spouse/Dom. Partner
pre-existing limitations may apply as explained in the
Tri-Care
Other ____________
Rights and Responsibilities brochure which I have
Dependent Children
I (we) have no other coverage at this time
received with this form.
Employee Initials Date
F. Signature
I authorize United HealthCare Insurance Company and its affiliates ("The Company
and Affiliates") to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in
these records. I understand these records may contain information created by other persons or entities (including health care providers) as well as
information regarding the use of drug, alcohol, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health
services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health
care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to The Company and Affiliates. I
(continued on back)
CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH CARE SERVICE
COMPANIES AND INSURANCE COMPANIES AS A CONDITION OF OBTAINING COVERAGE.
400-2251 4/06
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