Employee Enrollment Form Page 2
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4Last name:
First name:
Dental
Group #:
Benefit #:
Class/Div:
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
Prior dental coverage during the past 12 months (individual or other group coverage)?
m N m Y
Prior dental insurance carrier name
Prior coverage type:
Effective date
Policy #
m Employee only
_ _ / _ _ / _ _ _ _
m Employee and spouse
Prior orthodontia coverage in the past 12 months?
Term date
Prior carrier phone # (
)
m Employee and child(ren)
m N m Y
_ _ / _ _ / _ _ _ _
m Family
TX-72000-HD 5/2008
Basic Life
Group #:
Benefit #:
Class/Div:
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
Basic dependent life? m No m Yes
Class (employer will provide you
Annual salary (if applicable)
with this information if needed)
$
If no, complete waiver section.
TX-72000-BL 5/2008
Voluntary Life
Group #:
Benefit #:
Class/Div:
Voluntary employee life
Amount (min $15,000)
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
coverage? m N m Y
$
Voluntary spouse life
Voluntary child(ren) life coverage?
Amount (min. $5,000)
Annual employee salary (if applicable)
coverage? m N m Y
$
m N m Y
$
TX-72000-VL 5/2008
Vision
Group #:
Benefit #:
Class/Div:
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
TX-72000-VS 5/2008
Medical Health History
This information should not be submitted more than 60 days prior to the effective date.
1. Within the past 24 months have you or any dependent
2. Within the past 24 months have you
3. Have you or any dependent to be
to be covered had or been treated for an illness or
or any dependent to be covered been
covered incurred medical expenses
injury, had surgery or hospitalization recommended, or
prescribed medication? m N m Y
in excess of $7,500 in the past 12
are currently pregnant? m N m Y
months? m N m Y
If you answered “yes” to any of the questions above, please provide details below and specify the question number.
Attach additional signed and dated sheets if necessary.
Question # & letter
Person treated (Last name, First name)
Condition
Treatments received
Medications prescribed
Current or future treatments or medications
Date diagnosed _ _ / _ _ / _ _ _ _
Date last seen by a doctor _ _ / _ _ / _ _ _ _
Question # & letter
Person treated (Last name, First name)
Condition
Treatments received
Medications prescribed
Current or future treatments or medications
Date diagnosed _ _ / _ _ / _ _ _ _
Date last seen by a doctor _ _ / _ _ / _ _ _ _
Question # & letter
Person treated (Last name, First name)
Condition
Treatments received
Medications prescribed
Current or future treatments or medications
Date diagnosed _ _ / _ _ / _ _ _ _
Date last seen by a doctor _ _ / _ _ / _ _ _ _
TX-72000-MH 5/2008
TX-72000 5/2008
2
Reorder# TX-51340-SB 11/2008
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Parent category: Business