Form Gr-67971 - Dental Enrollment/change Request - Aetna Life Insurance Company
Download a blank fillable Form Gr-67971 - Dental Enrollment/change Request - Aetna Life Insurance Company 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 Form Gr-67971 - Dental Enrollment/change Request - Aetna Life Insurance Company 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
2Dental Enrollment/Change Request
Aetna Life Insurance Company *
Employer Name - Full Name of Business or Organization
Control
Suffix
Account
Plan Number
Employer Group Information:
(To Be Completed by Employer)
Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization
Group Number
Customer Code (Optional)
A. Type of Activity -
Employee Completes Sections A - E.
Please Print Clearly.
Continuation of Coverage, i.e., COBRA, State
Instructions: Refer to the instructions
Enrollment
Change
Remove or Terminate
- Not all options
- Check one.
- Check all that apply.
- Check all that apply.
Date of Event
on the back before completing this
are available. Contact Employer for available options.
New Enrollee/Subscriber
Rehire/Reinstatement
Add Spouse
Remove Spouse
form. You, the employee, must
Effective Date
Dependents
/
/
Coverage For:
Employee
Date of Rehire/Reinstatement
Add Dependent Child
Remove Dependent
Effective Date
complete this application in full or it
/
/
Length of Continuation:
18
36
Other
Child
Name Change
Reason
/
/
/
/
will be returned to you resulting in a
Employee Withdrawal/
29 -
Attach disability determination from the Social Security Admin.
Other
delay in processing. You are solely
Reason
Date of Hire
Termination
/
/
Date of Loss of Coverage:
responsible for its accuracy and
Control/Suffix/Acct/Plan
/
/
completeness.
Cancel Coverage
Date of Qualifying Event:
/
/
B. Employee Information
C. Plan Option -
Your selection must be offered by your employer.
Social Security Number
Last Name, First Name, M.I.
Primary Language Spoken
Check One:
Indemnity Dental
Dental EPP
FOC/Indemnity
Employee Home Address
Telephone Numbers
Employee Status
DentalFund/HealthFund
®
DMO
/Advantage/Basic
FOC/PPO
Number, Street, Apt
Home
(
)
Active
Dental PPO
FOC/DMO
Retired
Work
(
)
City, State
ZIP Code
D. Individuals Covered
- List individuals for whom you are adding/changing/removing coverage.
Attach sheet to list additional children.
Check this box if you are refusing coverage for your dependents.
Late
Prior
Other
Currently
Handi-
Student
Sex
Primary Dentist
Race/Ethnicity - Optional
(A)dd
Name (First, Middle Initial, Last)
Relation
Birthdate
Social Security Number
Dental
Covered by
capped
Code
Entrant
Insur.
(C)hange
Office ID Number
(This information is designed for the purpose of data collection and will not be used for
(Explain difference in last names in Special Remarks.)
(If dependent has no SSN, write "None")
(R)emove
M F
MM
DD
YYYY
Plan
Coverage
Medicare
determining eligibility, rating or claim payment.)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
White
01
African American or Black
02
-
-
/
/
Self
N/A
N/A
Hispanic or Latino
-
03
Asian
-
04
Other
-
05
White
01
African American or Black
02
-
-
/
/
Asian
04
Hispanic or Latino
-
03
-
Other
-
05
White
-
01
African American or Black
-
02
/
/
Hispanic or Latino
03
Asian
04
-
-
Other
-
05
White
-
01
African American or Black
-
02
/
/
Hispanic or Latino
03
Asian
04
Other
05
-
-
-
White
-
01
African American or Black
-
02
/
/
Hispanic or Latino
03
Asian
04
Other
05
-
-
-
Special Remarks
If "Yes" to Prior Insurance Plan, Other Dental Coverage or Medicare above, provide effective date, name & policy number of
insurance carrier, dental plan or other source.
Does any dependent listed in above live at a different address than the Employee? If "Yes," who and what address?
Yes
No
E. Employee Signature
F. Employer Verification -
To Be Completed by Employer
I represent that all the information supplied in this application is true and complete. I hereby agree to the conditions of
Employee Signature - Required
Employer Signature
X
X
enrollment on the reverse side of this application. I understand that in the event I fail to sign this form within 31 days after
the above transaction request or that for any reason Aetna does not receive notice of the above transaction request within
Date
E-Mail Address
Title
Date
a reasonable time following the event, my and my dependents' eligibility may be affected.
/
/
/
/
Please make a copy for your records.
visit us at
GR-67971 (7-03)
R-POD
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business