Form Sb.ee.10.fl - Employee Enrollment Form - 2010 Page 2

ADVERTISEMENT

Employee Name __________________________________________________________________________________________________________
Please check the box for each coverage you or your dependents are enrolling in.
If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount
C. Product Selection
selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability
(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.
Person
Medical
Dental
Vision
Basic Life/AD&D
Supp Life/AD&D
Employee
_____________
_____________
$_____________
$_____________
Spouse
_____________
_____________
$_____________
$_____________
Dependent
_____________
_____________
$_____________
$_____________
Person
STD
STD Buy Up
LTD
LTD Buy Up
Employee
$_____________
$_____________
$_____________
$_____________
Life Insurance Beneficiary’s Full Name and Address
Relationship
D. Prior Medical Insurance Information
This section must be completed to receive credit for prior medical coverage.
Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?
NO
YES (if yes, please complete this section.)
Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___
Prior coverage type:
Employee
Spouse
Child(ren)
Family
E. Other Medical Coverage Information
This section must be completed. (Attach sheet if necessary.)
On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,
including another UnitedHealthcare plan or Medicare?
YES (continue completing this section)
NO (skip the rest of this section)
Name of other carrier ______________________________________________________
Other Group Medical Coverage Information
Type
Effective Date End Date
Name and date of birth of policyholder
(only list those covered by other plan)
(B/S/F)*
MM/DD/YY
MM/DD/YY
for other coverage
Employee:
Spouse Name:
Dependent Name:
Dependent Name:
Dependent Name:
*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)
S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.
F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.
Medicare – Employee Information:
If enrolled in Medicare, please attach a copy of your Medicare ID card.
Enrolled in Part A: Effective Date _____________
Ineligible for Part A*
Not Enrolled in Part A (chose not to enroll)**
Enrolled in Part B: Effective Date _____________
Ineligible for Part B*
Not Enrolled in Part B (chose not to enroll)**
Enrolled in Part D: Effective Date _____________
Ineligible for Part D*
Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:
Over 65
Kidney Disease
Disabled
Disabled but actively at work
Are you receiving Social Security Disability Insurance (SSDI)?
YES
NO
Start Date ___ /___ /___
Medicare – Spouse/Dependent Name: ____________________________________________
Enrolled in Part A: Effective Date _____________
Ineligible for Part A*
Not Enrolled in Part A (chose not to enroll)**
Enrolled in Part B: Effective Date _____________
Ineligible for Part B*
Not Enrolled in Part B (chose not to enroll)**
Enrolled in Part D: Effective Date _____________
Ineligible for Part D*
Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:
Over 65
Kidney Disease
Disabled
Disabled but actively at work
*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.
** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain
coverage under Medicare Part A, Part B, and/or Part D as applicable.
Page 2 of 3

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 3