Enrollment Change Form - Request For Enrollment Change
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1
2Request for Enrollment Change
Group Name: ______________________ Group Number: __________Division:_____ Effective Date of Change:__________
Indicate Type of Change Below
NAME –
If your name has changed, please indicate YOUR PRIOR name so we can correctly identify you:
(NAME WAS)
ADD DEPENDENT
DROP COVERAGE (complete waiver on back)
DROP DEPENDENT (complete waiver on back)
CHANGE BENEFICIARY
NAME CHANGE
ADDRESS CHANGE
PHONE NUMBER CHANGE
:
EMPLOYEE INFORMATION
(REQUIRED)
Employee Last Name
Employee First Name
Social Security Number
Telephone Number(s)
Address
City
State
Zip
E-mail Address
CHANGE MY BENEFICIARY
(for plans with life insurance) Attach a separate sheet, if necessary:
Last Name, First Name
Relationship
Date of Birth
Complete Address
CHANGE MY ENROLLMENT AS INDICATED BELOW:
Resides With
Date of
MED
DEN
VIS
Last Name, First Name
Sex
Social Security #
Employee
Relationship
Birth
Add Drop Add Drop Add
Drop
YES / NO
Any dependents listed above must meet the definition of a dependent as listed in the Summary Plan Description.
If a dependent child is over the age of 19 (and if your plan requires this) is he/she a fulltime student/volunteer?
Yes
No
If yes, please indicate name of school or volunteer orgnization:
REASON FOR ADD/CHANGE (indicate below)
REASON FOR DROP (indicate below
DATE OF EVENT
)
DATE OF EVENT
Newborn
DOB
No Longer A Full Time Student
Adoption / Court Order (attach proof)
Divorce
Legal Separation
Marriage (date of Marriage required)
In Anticipation of Divorce
Other:
Ineligible Dependent
Reason:
Aged 19 or Over Dependent Returning to School :
(Date classes commence.)
Loss of Other Coverage:
Waiving Coverage: (You must complete the waiver
on the back of this form for every covered
Reason for loss of coverage______________________________
person including the reason.)
(You must provide a Certificate of Creditable Coverage.)
Other Insurance Information & Creditable Coverage Information Required:
Do you or your enrolled family members have any OTHER coverage? (That you will keep in addition to this coverage.)
YES
NO
* IF YES , please give name of each person covered, the other Plan Name, Address and Phone Number: ____________________________________
_______________________________________________________________________________________________________________________
Please include a copy of your Certificate of Creditable Coverage from your prior employer/carrier showing the effective date and termination date,
if applicable. *
I UNDERSTAND that providing inaccurate or incorrect information to any of the answers above may be considered health care fraud.
__________________________________________________________________
___________________________
Employee Signature
Date
(required)
(required)
ENROLLMENT CHANGE FORM 10/2005
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