Form Gr-67834-16 - Aetna New York Employee Enrollment Form
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1
2
3New York Small Group Business
(2 – 50 Eligible Employees)
Employee Enrollment/Change Form
Aetna Life Insurance Company
Aetna Health Inc.
151 Farmington Avenue
1425 Union Meeting Road
Hartford, CT 06156
Blue Bell, PA 19422
Aetna Health Insurance Company of New York
333 Earle Ovington Blvd., Suite 104
Uniondale, NY 11553
Life, Accidental Death & Dismemberment; Aetna EPO plans; Aetna Indemnity; and Aetna Managed Choice Plan PPO are provided by Aetna Life Insurance
Company; Aetna Primary Care Plan HMO; Aetna QPOS; and Aetna NYC Community Plan
are provided by Aetna Health Inc. and Aetna Health Insurance
SM
Company of New York. DMO
and PPO dental plans are provided by Aetna Life Insurance Company.
®
Member Aetna ID Number (if available)
Employer 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 B and D.
Effective Date
New Hire
Change of Coverage
Employee Termination
COBRA/State Continuation for:
Employee
Dependent
Rehire/Reinstatement
Add Spouse/Domestic
Remove Spouse/Domestic
Partner/Dependent Child
Partner/Dependent Child
Length of Continuation:
New Group Enrollment
Date of Hire
Cancel Coverage
Name Change
18
36
Other
Late Enrollment
Original Qualifying Event Date
Other
Other
A. Coverage Selection
Reason
Please print clearly, using black ink. (Shaded sections 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
2. Dental
3. Life and Disability
Open Access Elect Choice
®
(OA EPO) Plan Option:
Standard Plans:
Basic Life/AD&D Ultra
®
Option:
Optional Dependent Life
Open Access Managed Choice
®
(OA MC) Plan Option:
Options 3 & 8: DMO
or PPO
®
Life & Disability Packaged Plan
Out-of-State:
Open Access Elect Choice
(OA EPO) HSA Compatible
®
Beneficiary Designation - Full Name (First, Middle, Last)
Voluntary Plans:
Plan Option:
Option:
Open Access Managed Choice
(OA MC) HSA Compatible
®
Option 3: DMO
®
or PPO
Beneficiary Social Security Number
Plan Option:
Out-of-State:
NYC Community Plan
SM
Plan Option:
Relationship to Employee
Before today, were you covered under this
employer’s dental plan?
Yes
No
Indemnity Plan Option:
B. Employee Information
- Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Telephone
Primary Language Spoken
(Optional)
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Work Telephone
No. of Dependents Including Spouse/
No. of Hours Worked Per Week
Check One
Marital Status
Domestic Partner
Full-Time
Part-Time
Married
Single
1
GR-67834-16 (10-10)
NY - SGB R-POD L
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Parent category: Business