Group Enrollment Form printable pdf download

GROUP ENROLLMENT FORM

PLEASE PRINT CLEARLY IN BLUE OR BLACK INK

Group Number

Effective Date

LiUNA Local #1724

Group Name

 I apply for the following coverage for myself and dependents, as listed.

Managed Care Plan

 Summit

Employee First Name

Last Name

 M

Date of Birth

Facility ID #

 F

Employee Street Address

City

State

Zip

Employee Social Security Number

Home Phone

Work Phone

Division/Department/Class

Date of Hire

(

)

(

)

Dependents to be Included for coverage:

First Name

Last Name (if different)

Relationship

Sex

Date of Birth

Facility ID#

 M

 F

 M

 F

 M

 F

 M

 F

Check any boxes that apply and follow instructions:

 Are you covering more than three children? Please continue listing on additional Enrollment Forms.

 Is the address of any child different than the member’s? Show that child’s name & address on the back of this form.

 Are you requesting coverage for a dependent child other than a son or daughter? Forward legal custody paper.

Please note: Any person knowingly and with intent to defraud any insurance company, or other person who files an

application of statement claim containing any materially false information or concerning any fact material thereto commits a

fraudulent act, which is a crime.

 I elect not to have coverage for myself or my dependents and I hereby waive coverage under the above mentioned plans.

Signature:______________________________________________________________Date:________________________________________

To the best of my knowledge and belief, each of the statements and answers supplied in this form is complete and true, and they

constitute the sole basis for, and are the inducement for, the issuance of any coverage. Please read the following and sign below.

The Managed Care Plan is underwritten by United Dental Care of Utah, Inc.

I hereby apply for membership in this dental Plan for myself and for any eligible dependents listed above. I authorize the Group named

above to make deductions, if any, required as my contribution. I agree, for myself and for any eligible dependents listed, to abide by the

rules and regulations of the Plan and the terms and conditions of the Group Dental Service Agreement and Certificate of Coverage. I

authorize any licensed dentist, physician, hospital or other health care provider to furnish the Plan with any required dental or medical

information, as permitted by law about myself and any eligible dependents listed. I represent the information provided is true and correct

to the best of my knowledge. I further understand that my coverage and benefits may be affected by failure to provide complete and

accurate information. I will promptly advise the Plan and my Group of any changes in this information. The authorization is not governed

by HIPAA, however, when necessary, I may be asked to execute a HIPAA authorization form, allowing Union Security Insurance

Company to use and disclose protected health information.

Signature:______________________________________________________________Date:________________________________________

GEF-MCUT-NS 2/00

Non-Scannable Managed Care Group Enrollment Form

KC4125AUT (1/2006)

Group Enrollment Form

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