Form Ciefdpw-3 1/14 - Combined Insurance Enrollment Form
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4Combined Insurance Enrollment Form
Complete entire form to enroll or make changes.
Enrollment
Changes
Has there been a change that affects your insurance? Check all the changes that
apply to you and complete the entire form.
❏ New hire
❏ Name ❏ Address ❏ Marriage ❏ Domestic
❏ Divorce ❏ Legal separation ❏ Beneficiary
❏ New group
Partnership
❏ Open enrollment
❏ Other (be specific)
❏ Add dependent (check reason) ❏ Marriage ❏ Domestic Partnership ❏ Newborn
❏ Other reason (be specific)
Comments
❏ Drop dependent
Employee
Please print legibly in blue or black ink.
SSN
Employee Name (last, first, initial)
Date of birth
Gender
Date married:
Date divorced:
❏ Single
❏ Married
❏ Divorced
❏ Domestic partnership
❏ Partnership termination
Date met DP criteria:
Date terminated:
Home/mailing address
Phone (with area code)
City
State
Zip
Email address
Type of coverage requested (check all that apply):
❏ Medical ❏ Dental ❏ Life ❏ Long-term
❏ Vision
❏ EAP
Carriers and specific plans are listed on the back of this form.
disability
Are you covered by any other insurance now?
❏ Yes
❏ No
If yes, complete below.
Are you adding this coverage due to a recent loss of coverage? ❏ Yes
❏ No
Name of other insurance company
Type of insurance (medical. dental, etc.) Group#
Policy #
Effective date
Termination date
Insured’s SSN
Name (last, first, initial)
Spouse/
Please list spouse/domestic partner who should be covered on your insurance. Leaving them
off will terminate coverage. Proof of dependency will be requested, including, but not limited to,
Domestic Partner
marriage certificate, affidavit of marriage/domestic partnership, joint ownership documents.
SSN
Spouse/DP name (last, first, initial)
Date of birth
Gender
Type of insurance requested:
❏ Medical
❏ Dental ❏ Vision
❏ Life
Is spouse/domestic partner covered by any other insurance now? ❏ Yes
❏ No
If yes, complete below.
Are you adding this coverage due to a recent loss of coverage?
❏ Yes
❏ No
Name of insurance company
Type of insurance (medical. dental, etc.) Group#
Policy #
Effective date
Termination date
Phone #
Your signature is required on page 3 of this form.
CIEFDPW-3
1/14
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Parent category: Legal