Enrollment/change Form
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3Enrollment/Change Form
*Denotes required fields for enrollment. For items with ** please select a Reason for Enrollment OR a Reason for Change.
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EMPLOYER INFORMATION: To Be Completed By Employer
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New Group
New Enrollment
Change
Waive
Company Name:
*Group No.:
*Date Employed Full Time:
*Effective Date of Coverage or Change
**REASON FOR ENROLLMENT
**REASON FOR CHANGE:
(Please check all that apply and include supporting documentation.)
New Group
New Hire
Enroll Dependent
Terminate Dependent
Open Enrollment
Retired
Terminate Subscriber
Name Change (Previous Name)
COBRA
Qualifying Event (Reason)
Address/Phone
___________________________
Start: ___________
Date: ______________
Termination Reason:
Other ______________________
End: ____________
Group Request
Member Request
Deceased
EMPLOYEE STATUS:
Active
COBRA
Salary
Hourly/Numbers of hours a week ____
Other ________________________
B
SUBSCRIBER INFORMATION
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I ELECT THE FOLLOWING PLAN FOR MYSELF AND MY DEPENDENTS:
None/Waive (please complete Section E and F)
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Coventry Health Care of the Carolinas, Inc. POS ___
Coventry Health and Life Insurance PPO ___
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Other __________________
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Type of Coverage:
Employee
Employee/Spouse
Employee/Children
Employepouse/Children
*Last Name
*First Name
MI
*Gender
*Birthdate
*Social Security Number
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Male
Female
*Address
*City
*State
*ZIP Code
Email Address
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Marital Status (please check one.)
Single/Widowed
Married
Divorced
Separated
Work Phone
Home Phone
Tobacco Use In Last 6 Months?
Primary Care Provider
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Yes
No
PCP#:
PCP Name:
C
FAMILY MEMBERS TO BE COVERED OR DELETED
If address and phone numbers of covered dependents are different from that of policy holder, please attach that information on a separate sheet of paper.
Add
*Last Name
*First Name
MI
Delete
*Gender
*Relationship
Disabled
*Birthdate
*Social Security Number
Male
Spouse
Disabled
Female
Child
Tobacco Use In Last 6 Months?
Primary Care Provider
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Other __________________
Yes
No
PCP#:
PCP Name:
Tobacco includes cigarettes, pipe, cigars, snuff, or chewing tobacco used on average four times per week during the past six months. Religious or
ceremonial uses of tobacco (for example, by American Indians and Alaska Natives) are exempt.
NC ENROLL 2016
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