Form 290-536 - Enrollment Application/change/cancellation Request

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Enrollment Application/Change/Cancellation Request
■ Enroll
■ Address Change
■ Cancel
■ Name Change
■ Change
Date of Change____ /___ /____
To Be Completed By Employer
ATTENTION EMPLOYER REPRESENTATIVE: To ensure accurate processing of application, 1) please review all sections and confirm the
employee completed the appropriate information, 2) complete the information in this section and
3) provide your signature and
today’s date. If the employee is waiving coverage, do not submit the application but retain it for your records.
Company Name
Group #
Department #
Plan Variation
Reporting Code
Benefit Level/Class Code, if applicable
Medical ______
Vision ______
Medical ______ Vision ______
Life/AD&D ______ Suppl. Life
______
Dental
______
Life
______
Dental
______ Life
______
Spouse Life ______ Suppl. AD&D
______
Cancellations: Last Date of Employment ___ /___ /___
New Enrollment/Additions: (Check one)
Requested Effective Date of Cancellation ___ /___ /___
Date of Hire ___ /___ /___
Requested Date of Coverage ___ /___ /___
Cancel all coverage
New Hire
Status Change (PT to FT)
Cancel all listed below – Section B
Return from Leave/Layoff
Reason: (check one)
Birth
Marriage
Adoption
Death
Employee Terminated
Divorce
Court ordered dependent
Moved out of service area
Other (describe) ________________________
Dependent reached dependent max age
COBRA/State Continuation start date _______ stop date________
Other (describe)____________________________
Annual Open Enrollment Requested Effective Date of Enrollment ___ /__ /___
Employee Type
Union
Non-union
Salaried
Hourly
Active
Retire Date ______
COBRA/State Cont.
Signature ________________________________________________ Date ___________________
Employer Position_____________________________ Phone Number________________________
A. Employee Information
Last Name
First Name
MI
Social Security Number
Home Phone
Work Phone
Address
Apt #
City
State
Zip Code
Email Address
Date of Birth
Sex
Physician* (First & Last Name) / Physician’s ID Number
Primary Care Dentist Number*
M
F
/
/
Race – Check all that apply (Optional)**
Marital Status
Single
Married
American Indian/Alaska Native
Asian
Black/African-American
Hispanic/Latino
Divorced
Widowed
Native Hawaiian/Pacific Islander
White
Other–Please specify ___________________________
*IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care Dentist
(PCD) selection.
**Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being and
not for eligibility or claim payment determination.
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of Ohio or UnitedHealthcare of
Ohio, Inc.
Dental coverage provided by UnitedHealthcare Insurance Company
Life Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company
LG.EE.10.OH 7/10
LG EE 10 OH 7/10
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290 5362 10/10

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