Employee Enrollment Form
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Employee Enrollment Form
Indiana
To speed the enrollment process, please be thorough and fill out all sections that apply.
Group Name
To Be Completed by Employer
Requested Effective Date of Coverage/Date of Change
/
/
Group Name
Policy Number
Date of Hire
/
/
Employee Type
Reason for Application
(Check all that apply)
New Group Plan
New Hire
Life Event/Date_______
Annual
Active
COBRA
State Continuation
Position/Title
Status Change_______
Open
Start dt ____/____/____
Dependent Add/Delete
Enrollment
End dt____/____/____
Hours Worked per week
Change Name/Address
Late
Hourly
Salary
Part time to Full time
Enrollee
Union
Non-Union
Retired
Required only if Life, STD,
Waiving Coverage
Termination
Other ____________________________
Salary $_____________
Other _________________________
or LTD Plan based on salary
A. Employee Information
If you are waiving all coverage, please complete sections A and B.
Last Name
First Name
MI
Social Security Number
Address
Apt #
City
State
Zip Code
Home/Cell Phone
Date of Birth
Gender
Work Phone
Marital Status
Single
Married
Divorced
Widowed
M
F
/
/
Language Preference, if not English
Email Address
Do you use tobacco?
1
Yes
No
If yes, are you currently participating in a tobacco cessation
program or do you intend to join one?
Yes
No
Primary Care Physician
2
Existing Patient?
Yes
No
Primary Care Dentist
3
Physician First & Last Name _________________________________
Dentist First & Last Name _________________________________
Address _________________________________________________
ID# __________________________________________________
ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___
Existing Patient?
Yes
No
Declining coverage due to existence of other coverage:
B. Waiver of Coverage
I understand that by waiving coverage at this time, I
Spouse’s Employer’s Plan
Individual Plan
will not be allowed to participate unless I qualify at a
I decline all coverage for:
Covered by Medicare
Medicaid
special enrollment period or as a late enrollee, if
Myself
COBRA from Prior Employer
VA Eligibility
applicable, or at the next open enrollment period.
Spouse
Tri-Care
Dependent Children
I (we) have no other coverage at this time
Myself and all dependents
Other ____________________________________
Date
Employee Signature if waiving all coverage
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company or All Savers Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
241-11075 9/15
SG.EE.16.IN 4/15
Page 1 of 4
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Parent category: Medical