Form Ga-72000 - Humana Employee Enrollment Form - Dental, Life, Vision

Last name:

First name:

Waiver (refusal of coverage)

GA-72000-WV

3/2008

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I proclaim that I

was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage. If I have waived any coverage offered to me or my

dependents, my signature is evidence of this action.

I hereby waive coverage for (check all that apply):

I decline to apply for group coverage because of:

Dental for:

m Myself m My spouse m My dependent child(ren)

m Spousal coverage

Basic Life for: m Myself m My spouse m My dependent child(ren)

m Medicare supplement

Vision for:

m Myself m My spouse m My dependent child(ren)

m Individual coverage

m Coverage under another carrier’s plan provided by my employer

m Other:

Agreement

GA-72000-AA

3/2008

True and complete acknowledgement

I understand, agree and represent:

•

I have read this document or it has been read to me and answers provided are true and complete to the best of my knowledge and belief.

•

Neither my employer nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other rights

and requirements.

•

If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the certificate of coverage/certificate of insurance. If I

have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment with in 31

days after the qualifying event.

•

In the event that I should decide to apply for coverage hereafter, that subsequent application shall be subject to the applicable terms and conditions of the

master group contract(s) or plan provisions which may require additional limitations and waiting periods.

•

I may be required to furnish, at my own expense, evidence of health status satisfactory to Humana.

•

If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my

dependents provided that I request enrollment within 31 days after my other coverage ends.

•

Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future application for coverage.

•

If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize

Humana or its banking partners to provide my account number to my employer for the purposes of depositing any contributions.

•

Any intentional misrepresentation contained herein relied on by Humana may be used to reduce or deny a claims or void the contract within the contestable

period if such misrepresentation materially affected the acceptance of the risk.

• Medical coverage will not be declined due to health status.

• I have received a copy of the plan provider directory and disclosure that includes provider limitation rules and any financial arrangements with providers.

Authorization

My dependents and I authorize any third party to have information regarding myself and my dependents. This includes any medical or non-medical information and

to share any and all such information with Humana, its reinsurer or its legal representatives, and its affiliates.

My dependents and I understand and agree:

• The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for

benefits under an existing policy and plan administration.

• Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc. or

other persons or organizations performing health care operations or business or legal services in connection with an application, claim or as may be otherwise

lawfully required, or as I (we) may further authorize. Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this

authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements.

• A photographic copy of this authorization shall be as valid as the original.

• This authorization shall be valid for two years from the date shown below and I have the right to revoke this authorization at any time by writing to Humana’s

Privacy Office.

This document, together with any supplements, will form part of any contract and be the basis for any certificate of coverage/certificate of insurance issued.

Signature

GA-72000-SA

3/2008

- please sign below if enrolling or waiving group coverage.

If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the

inability to obtain the necessary information.

Employee or legal representative signature: _____________________________________________

Date: ____________________

Name and relationship of legal representative: _______________________________________________________________________

GA-72000 12/2007

Reorder# GA-51340-HD 12/2008