Transaction Form For Group Accounts
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2TRANSACTION FORM FOR GROUP ACCOUNTS
I. SUBSCRIBER INFORMATION
Last Name
First Name
M.I.
Sex
Social Security Number
Street Address
Apt.
City
State
ZIP Code
Were you ever a member of EmblemHealth?
Marital Status:
Birth Date:
Home Tel. #: ________________________
Email Address: ______________________________________________
Single
Married
NO
YES
Work Tel. #: ________________________
Mo. Day
Yr.
Domestic Partner
“GO PAPERLESS” and save trees (see back of form)*
If YES, member ID ______________________
Cell Tel. #: __________________________
Note: If electing Young Adult Coverage, please submit a completed Young Adult
Applicant’s hours worked per week:
Type of
Individual
Family
Coverage:
Employee & Spouse/DP
Employee & Child
at least 30 hours
less than 30 hours
COBRA
Election Form.
Primary Care Physician Name:
__________________________________________________________________ ID Number: ____________________________________________
(Not required for EPO/PPO members)
OB/GYN Selection Name:
____________________________________________________________________________________ ID Number: ____________________________________________
(Optional)
Are you covered by any other health insurance or Medicare?
Check One:
Status:
Transfer:
New Enrollment
Add Dependent
To Another Carrier
NO
YES If YES, indicate:
Reinstatement
Remove Dep.
EmblemHealth Group Change:
Insurance Co. Name: ______________________________________________________________________________________
Termination
Address Change
From: ___________________________
Insurance Co. Telephone #: ____________________ Type of Coverage: ______________
Change to Ind.
Name Change
To: _____________________________
Policy #: ____________________________________ Effective Date: _______________
II. ENROLLMENT INFORMATION — IF YOU ARE ENROLLING YOUR SPOUSE/DP AND/OR CHILDREN, PLEASE LIST EACH ONE BELOW — SEE ELECTION OF COVERAGE FOR ELIGIBILITY
Birth Date
Primary Care Physician
OB/GYN Selection
Note: A birth/marriage certificate or 1040 Form will be required for spouse/dependents with different last name.
✓ if
Name/ID Number
Name/ID Number
Last Name (if different)
First Name
Social Security Number
Sex
Relationship
Mo. Day
Yr.
Disabled
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(Not required for EPO/PPO members)
(Optional)
DEPENDENT
Spouse
DP
Child
Current Health Insurance Information:
Carrier Name: ____________________________________________________ Coverage Begin Date: __________________ Coverage End Date: __________________
DEPENDENT
Child
Current Health Insurance Information:
Carrier Name: ____________________________________________________ Coverage Begin Date: __________________ Coverage End Date: __________________
DEPENDENT
Child
Current Health Insurance Information:
Carrier Name: ____________________________________________________ Coverage Begin Date: __________________ Coverage End Date: __________________
For dependent adult children incapable of self-sustaining employment, please see Section A on the back side of this form to check the appropriate “Add Dependent” box, and follow the instruction for required documentation.
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Your signature is required to process this form. Your signature attests that you have read the reverse side of this form.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any material fact associated with such application commits a fraudulent insurance act. Such act is a crime, and will be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Applicant must sign here: ______________________________________________________________________________________________
Date: _
________________________________
III. EMPLOYER INFORMATION — THIS SECTION TO BE COMPLETED BY EMPLOYER/CONTRACTOR GROUP
Name of Group:
Group Number:
If you selected a small group metal plan, please check
EmblemHealth
GHI
GHI HMO
HIP
which type:
Gold
Silver
Bronze
Plan Name: ________________________________________
Requested Effective Date:
Hire Date:
Waiting Period:
Date Submitted:
Approved By: (Group Plan Administrator)
Medical:
Dental:
__________________
__________________
Instructions to Benefit Administrators or Group Representatives: For groups with 50 employees or fewer, you MUST complete Section A on the reverse side of this form. Required documentation MUST be attached to this Transaction Form to be processed.
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