Form Ga-72000 - Humana Employee Enrollment Form - Dental, Life, Vision - 2007
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Humana Employee Enrollment Form - Dental, Life, Vision
GEORGIA
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.
Life, and Vision plans insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company,
Humana Insurance Company, CompBenefits Insurance Company or CompBenefits of Georgia, Inc. CompBenefits Vision plan insured and administered by
CompBenefits Insurance Company.
Please print clearly and fill in each applicable circle.
Proposed effective date: _ _ / _ _ / _ _ _ _
Company name
Company city
State
Enrollment Information
GA-72000-EI
3/2008
Height
Weight
Full-time
Disabled?
Relationship
Last name, First name MI
Gender
student?
Date of birth
If yes, indicate reason.
(ft / in)
(lbs.)
Reason:
m F
m N
Employee
/
N/A
_ _ / _ _ / _ _ _ _
m M
m Y
Reason:
m F
m N
Spouse
/
N/A
_ _ / _ _ / _ _ _ _
m M
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Other (specify):
Reason:
m F
m N
m N
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
EMPLOYEE INFORMATION:
HOURS WORKED PER WEEK:
DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _
m RETIREE
SSN #
Street address
APT / Suite / Box
City
State
Zip code
Phone # (
)
Language: m English m Spanish
Email address
Dental
Group #:
Benefit #:
Class/Div:
GA-72000-HD
3/2008
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
Prior dental coverage during the past 12 months (individual or other group coverage)?
m N m Y
Prior coverage type:
Prior dental insurance carrier name
Effective date
Policy #
m Employee only
_ _ / _ _ / _ _ _ _
m Employee and spouse
Prior orthodontia coverage in the past 12 months?
Term date
Prior carrier phone # (
)
m Employee and child(ren)
m N m Y
_ _ / _ _ / _ _ _ _
m Family
Basic Life
Group #:
Benefit #:
Class/Div:
GA-72000-BL
3/2008
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
Class (employer will provide you
Annual salary (if applicable)
Basic dependent life? m No m Yes
with this information if needed)
$
If no, complete waiver section.
Voluntary Life
Group #:
Benefit #:
Class/Div:
GA-72000-VL
3/2008
Voluntary employee life
Amount (min $15,000)
Primary beneficiary name (Last, First MI)
Secondary beneficiary name (Last, First MI)
coverage? m N m Y
$
Voluntary spouse life
Voluntary child(ren) life coverage?
Amount (min. $5,000)
Annual employee salary (if applicable)
coverage? m N m Y
$
m N m Y
$
Vision
Group #:
Benefit #:
Class/Div:
GA-72000-VS
3/2008
Coverage type:
Plan name
m Employee only
m Employee and spouse
m Employee and child(ren)
m Family
m NO COVERAGE (complete waiver)
GA-72000 12/2007
1
Reorder# GA-51340-HD 12/2008
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Parent category: Business