Request For Group Coverage/enrollment Form Page 2
Download a blank fillable Request For Group Coverage/enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Request For Group Coverage/enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6Please read and fill out ALL applicable sections carefully.
1. Employer Section
Please print or type.
Location Name:
Location#:
First Active Day of
Enrollment Use Only:
Work:
Effective Date of Coverage:
Annual Salary:
Occupation:
2. Employee Section
Employee’s
Employee’s First
Last Name:
Name:
Employee’s Home Address:
City:
State:
Zip Code:
Employee’s Soc. Sec. #:
Date of Birth:
Email Address:
Home Phone:
Male
Female
Religious
Single
Married
Widowed
Divorced
I request to be covered for the applicable benefits of my Group Plan as:
or
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee, Spouse and Child(ren)
Please Complete section below if selecting dependent coverage.
Must be completed entirely or can result in delay.
List the name of each dependent and
Social Security Number
Birthdate MM/DD/YY
Sex
Are you legal
Step-child
answer each question for each
F/M
Guardian
dependent.
Spouse:
N/A
N/A
List Children Below
1.
2.
3.
4.
5.
6.
Signature of
Date:
Employee:
3. Waiver Of Group Coverage
I hereby certify that I have been given an opportunity to apply for group coverage. I understand that
if I waive coverage at this time, future coverage may be delayed. I decline to enroll:
Myself
My Dependents for Coverage(s) because:
Enrolled on Spouse’s Plan
Individual Policy
Medicare
Medicaid
Enrolled with another employer plan
Other (please explain____________________
Signature of
Effective
Date:
Employee:
Date:
Rev.9/23/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical