Enrollment/change Form

Enrollment/Change Form

New & Existing Groups

P 888.313.7277

F 888.354.7277

 Medical

 Life/ADD/LTD

A.

 _____/_____/_______

Enrollments/Additions

Enroll in:

 Dental

 ID Theft

Requested Effective Date

(Complete A, E, F, N, O)

(Select all that apply)

 Vision

(1

st

of month only other than birth)

(Select Coverages G-M)

 Open Enrollment/Renewal

 New Hire

 Re-hire

Reason:

 Add Dependent

 Status Change

 Involuntary Loss of Coverage



 Date of Birth:

____/____/_____

(Part to Full-time)

 Other _______________________________

(Select One)

 Date of Marriage: ____/____/_____

____/____/_____

 Adoption

(requires legal documentation)

The following documents are required and must be submitted within 30 days of an associated qualifying event:

HIPAA Certificate if enrolling due to loss of coverage; Marriage Certificate if enrolling a spouse due to a qualifying event; Birth Certificate if adding a dependent child; Declaration of Cohabitation & Financial

Interdependence Form if enrolling a domestic partner due to a qualifying event. Note: Additional documentation may be required.

Covered elsewhere?

 ____/____/____

 Medical

 Y  N

B.

Waive Coverage

Waive coverages:

Requested Date to Waive Coverage

 Dental

 Y  N

(Select One)

(Complete B, E, N, O)

(1

st

of month only)

 Vision

 Y  N

C.

Change

 Name Change

 Address Change

Change Type:

Requests

 ____/____/____

 Other: _____________________________

(Select One)

Requested Effective Date

(Complete C, N, O)

(List changes in E, F)

Requested Termination Date (must be the

 Medical

 Dental

 Vision



Life/ADD/LTD



ID Theft

 __/__/__

last day of a month)

 Employee

 Employee

 Employee

 Employee

 Employee

D.

 Spouse

 Spouse

Terminations

Reason:

 Spouse

 Spouse

 Spouse

 Child(ren)

 Child(ren)

 Child(ren)

 Child(ren)

 Child(ren)

1

1

1

1

1

 No Longer Employed

(Complete D, E, F

, N, O)

1

 Cancel Coverage

 Other_____________

Indicate the coverages and members to terminate above.

If terminating coverage for one or more child(ren)on the policy (but not all), list in Section F the child(ren) who should have their coverage terminated. If no

1

child(ren) are separately listed in Section F, all dependent children on the policy will be terminated.



E.

Employee Information

Group Name

Hire Date* (MM/DD/YYYY)

Prefix

First Name*

Middle Initial

Last Name*

Suffix

Social Security #*

Date of Birth* (MM/DD/YYYY)

 Male

 Divorced

 Legally Separated

 Single

Gender*:

Marital Status:

_____/_____/________

 Female

 Domestic Partner

 Married

 Widowed

Address*

Apt

City/State/Zip*

County

Home Phone

Cell Phone

Home Email

 Home

Work Phone/Ext

Work Email

Preferred Email:

 Work

F.

Dependent Demographics

Dependent 1

Prefix

First Name*

Middle Initial

Last Name*

Date of Birth* (MM/DD/YYYY)

Social Security #*

_____/_____/________

 Male

Disabled?

 Yes

 Divorced

 Legally Separated

 Single

Gender*:

Marital Status:

 Female

 No

 Domestic Partner

 Married

 Widowed

)

(Requires Additional Documents

 Spouse

 Child

Relationship*:

 Domestic Partner

 Domestic Partner Child

Dependent 2

Prefix

First Name*

Middle Initial

Last Name*

Date of Birth* (MM/DD/YYYY)

Social Security #*

_____/_____/________

 Male

Disabled?

 Yes

 Divorced

 Legally Separated

 Single

Gender*:

Marital Status:

 Female

 No

 Domestic Partner

 Married

 Widowed

)

(Requires Additional Documents

 Spouse

 Child

Relationship*:

 Domestic Partner

 Domestic Partner Child

Dependent 3

Prefix

First Name*

Middle Initial

Last Name*

Date of Birth* (MM/DD/YYYY)

Social Security #*

_____/_____/________

 Male

Disabled?

 Yes

 Divorced

 Legally Separated

 Single

Gender*:

Marital Status:

 Female

 No

 Domestic Partner

 Married

 Widowed

)

(Requires Additional Documents

 Spouse

 Child

Relationship*:

 Domestic Partner

 Domestic Partner Child

*

REQUIRED FIELDS

V1 of 1 9/2017