Form Il-80124-Cg - Humana Change Form
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2Humana Change Form
ILLINOIS
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana.”
HMO plans offered by Humana Health Plan, Inc. PPO, Classic and Indemnity Medical plans and LIfe and Short Term income protection plans insured or
administered by Humana Insurance Company. Dental PPO and Traditional Preferred plans insured or administered by HumanaDental Insurance Company
or Humana Insurance Company. Dental Prepaid plans underwritted by The Dental Concern, Ltd.
Please print clearly and fill in each circle where applicable.
Group number
Benefit number
Class/Division
Employee information
Last name
First name
MI
Member ID
Employer name
Change employee address information
New street address
Apt / Suite / PO box number
City
State
Zip code
E-mail address
Phone number
Change or select primary care physician (HMO and POS only)
Employee’s primary care physician
Physician ID
Dependent last name
First name
MI
Dependent’s primary care physician
Physician ID
Change or select primary care dentist
Group number
Employee’s primary care dentist
Dentist ID
Employee’s primary care clinic
Dependent last name
First name
MI
Dependent’s primary care dentist
Dental Network
Dependent’s primary care clinic
Dentist ID
Change plans or dependents
Change plan from ______________________________________ to ______________________________________
If changing to an HMO, POS, PPO, Traditional Preferred or Prepaid plan, please select a primary care physician/dentist and enter on previous page.
Change benefit / class to:
Benefit number
Class/division
Add dependent (complete Dependent Information form and any applicable enrollment forms)
Delete dependent (complete Dependent Information form and any applicable enrollment forms)
Cancel coverage:
Termination date (MMDDYYYY)
Indicate qualifying event:
Re-hire
Divorce
Dependent birth / adoption
Legal separation
Spouse’s employer terminates coverage
Other: ____________________________
Employer contribution ceases
Spouse deceased
Qualifying event date (MMDDYYYY)
Spouse changes from full-time to part-time employment
Spouse terminates employment
IL-80124-CG
Reorder# IL-99955-CG 8/2004
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Parent category: Business