Form Ebd - Member Enrollment Form

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MEMBER ENROLLMENT FORM
EBD187
12 Trafalgar Road, Kingston10, Jamaica W.I.
Tel.: (876) 978-4473 Fax.: (876) 927-4732
PLEASE USE BLOCK LETTERS WHEN COMPLETING THIS FORM
Toll Free: 1-888-MEDECUS
Website:
FOR EMPLOYER USE
EMPLOYER/COMPANY NAME
GROUP No.
Div. No
EMPLOYMENT DATE
LOCATION
INS CLASS
DD
MM
YY
EFFECTIVE DATE *
Select
NEW HIRE:
DD
MM
YY
Select
OPEN ENROLLMENT:
REMARKS:
MEMBER/
MEMBER No.
EMPLOYEE NAME
(LAST NAME,
FIRST NAME,
MIDDLE INITIAL )
1
3
3
3
DATE OF BIRTH
SEX
DD
MM
YY
M
F
MARITAL STATUS
OCCUPATION
Select
Select
PHONE NUMBER
TRN
Home
2
Cell.
DEPENDENTS
RELATIONSHIP
SEX
DATE OF BIRTH
TRN
LAST NAME (If Different)
FIRST
M.I.
M
F
DAY MO.
YR
TO EMPLOYEE
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
BENEFITS ELECTED
MEDICAL
Select
Select
Select
Select
Select
As provided under my Employer's Group Contract with Guardian Life Limited, I elect coverage as indicated above on behalf of myself and my eligible
dependent(s) as listed above (where applicable) and authorize my employer to deduct from my earnings the contributions required (if any) for
the benefits elected.
Having elected a Medical, Dental and/or Optical Plan, I authorize Guardian Life Limited to have access to, and copies of, all medical, Hospital or
other institution/agency records relating to the diagnosis, treatment or services provided to me or a covered dependent.
I certify that the above information is correct to the best of my knowledge and confirm that I understand the conditions as stated above.
* I understand that the Effective Date of this insurance is subject to (a) my being actively at work on the day in question; (b) the rules and conditions
of the company's underwriters as set forth in the Group Insurance Contract.
SIGNATURE OF EMPLOYEE:
DATE:
(If employee is applying for coverage outside of eligibility period, please complete the Health History Questionnaire)
MEF 1.07
FORM # EBD.E
0007/00187
03/2010;
FOR OFFICIAL USE: Index by Member No., TRN, Name of Member

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