Enrollment Form

Send completed forms to:

Enrollment Form

PHP Insurance Company

PO Box 399,

Linthicum, MD, 21090-0399

Or Fax to: (517) 364-8416

ATTN: Enrollment Department

PLEASE PRINT LEGIBLY

Application for:

Medical

Delta Dental

Waiver of Coverage:

I decline coverage for:

Employee & all dependents

Spouse only

Dependents only

Reason:

Covered under another health plan

Other (specify): _____________________

A. Employee & Family Information

Employee’s  

First

Middle

Social Security

Last Name

Name

Initial

Number

Street

City

State

Zip

Address

PO Box

Apt. No.

Home

Work

Email

Language preference

Phone (

)

Phone (

)

@

Date

Gender

Ethnicity

Marital Status:

Single

Married

Divorced

of Birth

Widowed

Separated

Independent Contractor?

Primary Care Physician

Current Patient?

Yes

No

Y / N

Last Name/First Initial

City/Phone

Please list family members to be covered under this policy. Please attach additional form if needed. Write name as it should appear on ID Card.

Dependent may not be eligible if other medical coverage is available to them through their employer.

Social Security

Medical Insurance

Primary Care Physician

Current

Patient?

First Name

M.I.

Last Name

Number

Relationship

Gender

Date of Birth

available from

First & Last Name

his/her employer?

Y / N

Y / N

1

Y / N

Y / N

2

Y / N

Y / N

3

Y / N

Y / N

4

Y / N

Y / N

5

B. Coordination of Benefits – (

Failure to complete this section may result in delays in enrollment or claim payments

)

On the day your coverage begins, will any family members above be covered by other medical, dental or Medicare insurance?

Yes If yes, please complete this section and attach a copy of the card. Please use extra paper if more than one additional policy will be in force.

No

Coverage type (please attach copy of other medical insurance card):

Name of

Policy Holder

Medical Insurance

Medicare

Dental Insurance

Policy Holder

Date of Birth

Insurance Company

Policy

Policy  Holder’s  

Name & Phone Number

Number

Employer

Medicare Part A

Medicare Part B

Medicare Part D

Medicare Part C

Medicare

Policy Number

Effective Date

Effective Date

Effective Date

Effective Date

Reason for Medicare:

End Stage Renal Disease

Please list everyone

Coverage

Disability

Over age 65

Over age 65 and working

covered by other insurance:

Dates:

C. Employee Signature – this form must be signed by the employee even if waiving coverage.

ACCURACY OF INFORMATION:    On  behalf  of  myself  and  anyone  enrolled  on  or  added  to  this  application  (“Us”),  I  understand  and  agree  that  any  omissions  or incorrect statements

knowingly made by Us on this  application  may  invalidate  my  and/or  my  dependents’  coverage.    NOTICE OF ENROLLMENT RIGHTS: I understand that if I decline enrollment for myself

or my dependents (including my spouse) because of other health coverage, I may be able to enroll myself and my dependents in this policy if I or my dependents lose eligibility for that other

coverage  (or  if  the  employer  stops  contributing  towards  my  or  my  dependents’  other  coverage).    However,  I  must  request  enrollment  within  30  days  after  my  or  my  dependents’  other coverage

ends (or after the employer stops contributing toward the other coverage). In addition, I understand that if I have a new dependent as a result of marriage, birth, adoption or placement for

adoption, I may be able to enroll myself and my dependents. However, I must request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. To request

special enrollment or obtain more information, I can contact PHP Customer Service at (517) 364-8500.

Employee Signature _______________________________________________________________________________________ Date Signed ___________________________________

D. For Employer Use only – must be completed in order to process

Group

Group

Sub Group

Class

Effective

Name

Number

Number

Number

Date

Qualifying

Qualifying event reason:

Open Enrollment

Full Time

Union

Salaried

event date:

New Hire

Return

Status Change

Part Time

Non Union

Hourly

Other (Specify)

___________________________________

Employer Representative Printed Name: _____________________________________________________________ Phone Number: ________________

Employer Representative Signature (required): _______________________________________________________ Date Signed:___________________

For questions regarding this form, please e-mail – or call the PHP Enrollment Department at (517) 364-8320

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Medical coverage is a product of PHP Insurance Company

Dental Insurance is a product of Delta Dental Plan of Michigan