Form Eb4633 - Enrollment Change Request Form

ADVERTISEMENT

Registered marks of Fort Dearborn Life
Insurance Company
Enrollment Change Request Form
(This form should be used for miscellaneous membership changes. It cannot be used for open enrollments
or for additions of any type and must be completed by a Group Administrator.)
Please complete in black ink, keep second part for your records and third part for your employee’s records.
Employer Name ______________________________________________ Group/Section # ______________________________
Member Name ________________________________________________ Social Security Number ( SSN ) _____-___-________
This request is a change for: ❑ employee
❑ dependent
❑ all family members
MM
DD
YYYY
Spouse’s Name ____________________________SSN: ______-____-________ Date of Birth ___/___/_____
For dependent change:
MM
DD
YYYY
Child’s Name ____________________________SSN: ______-____-________ Date of Birth ___/___/_____
❑ Change Name to
____________________________________________________________________________________________
❑ Change Address to
__________________________________________________________________________________________
Medicare:
❑ Employee
❑ Spouse
❑ Child is now Medicare eligible. Please complete the section below:
HIC #
Medicare B
ESRD Dialysis
Disability
Medicare A
Start Date:
Start Date:
Start Date:
Start Date:
End Date:
End Date:
End Date:
Termination/Continuation of Coverage:
❑ Health Coverage
❑ Dental Coverage
❑ Life Coverage
Due to:Left Employment
As of: ___/___/___
IL Continuation ended
As of: ___/___/___
Child reached limiting age
As of: ___/___/___
COBRA Eligibility begun
As of: ___/___/___
No longer full time student
As of: ___/___/___
COBRA ended
As of: ___/___/___
Divorce
As of: ___/___/___
Death (effective date is date AFTER death)
As of: ___/___/___
IL Continuation begun
As of: ___/___/___
Other (explain) __________________________ As of: ___/___/___
Changes to Life Benefit and/or Beneficiaries:
Amount of Life Insurance Give new salary $_______________ ❑ hourly
❑ weekly
❑ monthly
❑ annually
Amount of Insurance AFTER change $_______________________________
New Job Title ____________________________________________________
Beneficiary(ies) –This revokes any current beneficiary designations. Change my beneficiary(ies) to:
1) Last Name ________________________First Name ______________________Relationship ______________Date of Birth___/___/___
Address _______________________________________________________________________________________________________
2) Last Name ________________________First Name ______________________Relationship ______________Date of Birth___/___/___
Address _______________________________________________________________________________________________________
Employer or Group Administrator Signature
Date
EB4633 11/03
®
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
®’
Registered Service Mark of Fort Dearborn Life Insurance Company, an Independent Licensee of the Blue Cross and Blue Shield Association

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go