Hint Group Enrollment - Group Enrollment/change Request Form Page 2
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7B. [Employee] Information – to
Name (Last, First, MI):
SSN:
be completed by the [Employee]
Birthdate (mm/dd/yyyy):
Male
Street/Apt:________________________________________________________________________________________
Female
Street/Apt:________________________________________________________________________________________
Phone: (_____)________________
City:___________________________________________________ State:_____ Zip Code: _____________________
[Email: _______________________________]
[Employer] Name:__________________________________________________________________________________
Phone: (_____)__________________
Address:__________________________________________________________________________________________
[Email:
City:___________________________________________________ State:_____ Zip Code: ______________________
_________________________________]
Employment Date: _____/_____/_____
Hours worked per week:_________
Add
Remove
Continuation
Other Change If a name change, indicate prior name:
[Primary ________________________________________________________________________
[NPI #:]
[Current Patient:
Yes
address:
zip+4
]
No]
[Ob/Gyn ________________________________________________________________________
[NPI #:]
[Current Patient:
Yes
address:
zip+4
]
No]
[Dentist _______________________________________________________________________
[NPI #:]
[Current Patient:
Yes
address:
zip+4
]
No]
Other Health Coverage?
Yes
No If yes:
[Other Rx Coverage?
Yes
No If yes:
Payer Name: ____________________________________________________________
Payer Name: ____________________________________________________________
Policy #: ________________________________________
Policy #: ___________________________________________
Medicare ID#, if any:
Medicare ID#, if any:
]
Previous Coverage?
Yes
No
Payer Name:____________________________________________________________
If Yes:
Policy #:____________________________
Effective date: _____/_____/_____
Termination date: _____/_____/_____
[Submit a Certificate of Creditable Coverage]
C. Plan Option – to be completed by the [Employee] Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status]
D. Other Individuals Covered – to be completed by the [Employee] Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage.
Attach additional pages if necessary, with your signature and dated. [Attach proof if full-time post-secondary student.] [Attach proof of disability.]
1. Spouse; Domestic or Civil Union
2.Child
3. Child
4. Child
Partner
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Other
Continue Spouse
Other
Continue
Other
Continue
Other
Continue
Continue CU Partner (NJSGC)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
L:________________________________
L:_________________________________
L:_________________________________
L:_______________________________
F:________________________________
F:_________________________________
F:_________________________________
F:_______________________________
MI:
MI:
MI:
MI:
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
NJ-HINT-Group
2
[Internal Carrier Form Number]
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