Fillable Form Gr-68753-6 (4-12) - Pennsylvania Employee Enrollment Change Form

NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your

health information by taping or stapling the form so that pages 2 through 4 are not visible.

Pennsylvania

Group Number

Employee Enrollment/Change Form

Member Aetna ID Number (if available)

(2 - 100 Eligible Employees)

Company Name

INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to

you resulting in a delay in processing. You are solely responsible for its accuracy and completeness. If

waiving coverage, please complete Sections A and B.

Effective Date

COBRA

Continuation for:

Change of coverage

Employee Termination

New Hire

Waiver

Employee

Dependent

Add Spouse/

Remove Spouse/

Rehire/Reinstatement

Other

Domestic Partner

Length of Continuation:

New Group Enrollment

Other

Add Dependent Child

Remove Dependent Child

Date of Hire

Late Enrollment

Original Qualifying Event Date

Name Change

Cancel Coverage

Open Enrollment

Other

Qualifying Event

A. Employee Information

- Must be completed by the employee.

Last Name, First Name, M.I.

Marital Status:

Single

Married

Divorced

Widowed

Legally Separated

Home Address

Apt. No.

City, State

ZIP Code

Work Address

City, State

ZIP Code

Home Telephone

Work Telephone

Job Title

Primary Language Spoken (Optional)

B. Waiver of Coverage -

To be completed if medical and/or dental coverage is declined or refused by an eligible employee and/or their eligible family members.

Reason for declining coverage

Medical declined for:

Myself

Spouse/Domestic Partner

Child(ren)

Spousal group coverage

COBRA coverage

Medicare

TRICARE Military coverage

Dental declined for:

Myself

Spouse/Domestic Partner

Child(ren)

Medicaid

Another group plan provided by my employer

Life declined for:

Myself

Spouse/Domestic Partner

Child(ren)

Individual coverage

Do not want

Retiree coverage

Disability declined for:

Myself

Other

I acknowledge I have been given the right to apply for this coverage, however, I am electing not to enroll. By declining this group coverage I acknowledge

that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage. Pre-existing conditions, when

enrolled in other than an HMO plan, may not be covered for twelve months. NOTE: If your Plan contains a pre-existing conditions provision, the pre-existing

conditions exclusion and limitation will not apply to a person under 19 years of age.

Date (Month/Day/Year)

Please sign here ONLY if you are declining coverage for yourself or dependent(s).

Employee Signature

C. Coverage Selection

Please print clearly, using black ink. (Top boxes for Employer/Aetna Use Only)

–

Control/Group No.

Suffix

Account

Plan No.

Class Code

Control/Group No.

Suffix

Account

Plan No.

Control/Group No.

Suffix

Account

Plan No.

1. Medical

Yes

Dental

Yes

3. Life and Disability

Yes

To enroll, enter plan option elected next to the plan type below:

To enroll, enter plan number and name elected below.

Basic Life/AD&D Ultra

POS – Plan Option

RX Option

Contributory Plan:

Optional Dependent Life

Plan Number:

POS No Referral – Plan Option

Life & Disability Packaged Plan

RX Option

Plan Name:

Beneficiary Designation - Full Name (First, Middle, Last)

If Freedom-of-Choice, check:

DMO

PPO

POS Cost-Sharing – Plan Option

RX Option

Voluntary Plans:

CalYr

Pln Yr

Plan Administration

Plan Number:

Beneficiary Social Security Number

POS Cost-Sharing No Referral –

Plan Name:

Plan Option

RX Option

If Freedom of Choice, check:

DMO

PPO

Relationship to Employee

Plan Administration

CalYr

Pln Yr

POS HSA Compatible No Referral –

Plan Option:

Before today, were you covered under this

employer’s dental plan?

Yes

PPO – Plan Option

RX Option

PPO Cost-Sharing – Plan Option

RX Option

Plan Administration

CalYr

Pln Yr

PPO HSA Compatible – Plan Option:

Health Network Option AHF HRA –

Plan Option

Indemnity – Plan Option:

Other Plan – Plan Option

GR-68753-6 (4-12)

R-POD A

Form Gr-68753-6 (4-12) - Pennsylvania Employee Enrollment Change Form - Aetna

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