Fillable Enrollment/change Request Form - Aetna Life Insurance Company printable pdf download

Enrollment/Change Request

Aetna Life Insurance Company

Employer Name - Full Name of Business or Organization

Control

Sufﬁ x

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 (IMO Only)

Customer Code (Optional)

Continuation of Coverage, i.e., COBRA, State

- Not all options

A. Type of Activity -

Employee Completes Sections A - E.

Please Print Clearly.

are available. Contact Employer for available options.

Enrollment

Change

Remove or Terminate

Instructions: Refer to the instructions

- Check one.

- Check all that apply.

Employee

Dependents

Coverage For:

Date of Event

Add Spouse

New Enrollee/Subscriber

Rehire/Reinstatement

Remove Spouse

on the back before completing this form.

Length of Continuation (months):

Other

Effective Date

Date of Rehire/Reinstatement

Add Dependent Child

You, the employee, must complete this

Effective Date

Remove Dependent

29 -

Attach disability determination from the Social Security Admin.

Child

application in full or it will be returned

Reason

Name Change

Date of Loss of Coverage

to you resulting in a delay in process-

Other

Employee Withdrawal/

Reason

Date of Hire

Date of Qualifying Event

Termination

ing. You are solely responsible for its

Control/Sufﬁ x/Acct/Plan

Continuation of Coverage Expiration Date

accuracy and completeness.

Cancel Coverage

B. Employee Information

C. Plan Options -

Your selection must be offered by your employer.

Social Security Number

Last Name, First Name, M.I.

Home Telephone

Work Telephone

Check One:

(

)

(

)

Aetna Choice

POS II

Managed Choice

POS

Employee Status

Home Address

Apt. No.

City, State

ZIP Code

Aetna HealthFund

Open Choice

PPO

Active

Retired

Aetna Open Access

Elect Choice

Traditional Choice

Social Security Number of

Relationship to Employee Earnings

Beneﬁ ciary Designation - Full Beneﬁ ciary Name (First, Middle, Last) If more than

Insurance Amount

Aetna Open Access

Managed Choice

Other

one beneﬁ ciary, use Special Remarks (Section D).

Beneﬁ ciary

Annually

Supplemental Life

Elect Choice

EPO - For Self-Insured Plans Only

Weekly

AD&D Amount

While the Federal Patient Protection and Affordable Care Act generally mandates coverage of dependent children up to age 26, your plan may allow coverage beyond age 26. Please refer to your plan documents or contact your beneﬁ ts administrator.

D. Individuals Covered

- List individuals for whom you are adding/changing/removing coverage.

Check this box if you are refusing coverage for your dependents.

Provide details for "Yes" responses below.

Name (First, Middle Initial, Last)

Prior

Other

Handi-

Race/Ethnicity - Optional

(A)dd

Relation.

Sex

Birthdate

Social Security Number

Primary Medical

Current

Code

Insur.

Medical

Rx Drug

capped

(This information is designed for the purpose of data collection and will not be used

(C)hange

Patient

(Explain difference in last names in Special Remarks.)

(If dependent has no SSN, write "None")

Ofﬁ ce ID Number

M F

YYYY

Coverage

Plan

for determining eligibility, rating or claim payment.)

(R)emove

Yes

Code

Other

Using the KEY below, please identify the

Self

N/A

Race/Ethnicity code for each individual.

KEY:

01 - White

02 - African American or Black

03 - Hispanic or Latino

04 - Asian

05 - Other (Provide race/ethnicity in

"Other" column at left)

Yes

1. If "Yes" to Prior Insurance Plan and/or Other Medical Coverage above, provide effective dates, name & policy number

3. Does any dependent listed above live at a different address than the employee? If "Yes," who and what address?

of insurance carrier, HMO or other source and your Member Identiﬁ cation Number.

Special Remarks

2. If "Yes" to Other Rx Drug Coverage above, provide effective dates, name & policy number of insurance carrier, HMO or

other source and your Member Identiﬁ cation Number.

E. Employee Signature

By checking this box you agree to use Aetna's member self-service website for all future printed materials and understand you may choose to receive paper documents in the future. To view this material please visit Aetna Navigator

Employee Signature - Required

Primary Language Spoken

I certify that all information supplied in this form is true and complete to the best of my knowledge

and/or belief. I have read and agree to the Conditions of Enrollment on the reverse side of this

Date

E-Mail Address

Enrollment/Change Request form.

Please make a copy for your records.

visit us at

GR-68000-12 (9-10)

NC V1 R-POD B