Form Gr-67834-2 - Aetna Texas Employee Enrollment/change Form

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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 and 3 are not visible.
Texas Small Group Business
Employee Enrollment/Change Form
Social Security Number
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 G.
Effective Date
New Hire
Change of coverage
Employee Termination
COBRA/State Continuation for:
Employee
Dependent
Rehire/ Reinstatement
Add Spouse/Domestic Partner/
Remove Spouse/
Dependent Child
Domestic Partner/
Date of Hire
New Group Enrollment
Length of Continuation:
Dependent Child
Name Change
18
36
Other
Late Enrollment
Cancel Coverage
Other
Other
Original Qualifying Event Date
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.
2. Dental -
3. Life and Disability
To enroll, enter plan number and name elected
1. Medical
- Check one.
below.
Aetna HMO Plus/QPOS Plan –
Basic Life/AD&D Ultra
®
Standard Plan:
Optional Dependent Life
Plan
Plan Number:
Life & Disability Packaged Plan
Plan Name:
Aetna CPOS Plan –
If Option 3, check:
DMO
or
PDN
®
Plan
Beneficiary Designation - Full Name (First, Middle, Last)
Voluntary Plans:
Aetna OA MC Plan –
Plan Number:
Plan
Plan Name:
Beneficiary Social Security Number
If Option 3, check:
DMO
or
PDN
®
Aetna PPO Plan –
Out-of-State PDN Plans:
Plan
Plan Name:
Relationship to Employee
Aetna Indemnity Plan
Before today, were you covered under this employer’s
dental plan?
Yes
No
B. Employee Information
- Must be completed by the employee.
Member ID Number (If Available)
Last Name, First Name, M.I.
Job Title
Home Telephone
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Work Telephone
No. of Hours
No. of Dependents
Salary
Check One
Marital Status
Worked Per Week
Including Spouse/
$
Hourly
Weekly
Monthly
Full-Time
Part-Time
Married
Single
Domestic Partner
Subscriber Primary Language (other than English) Primer Idioma del suscriptor (que no sea el Ingles)
Subscriber Disability
What is your primary Language?
Do you have a disability which affects your ability to communicate or read?
Yes
No
¿Cuál es su primer idioma?
If Yes, please indicate the nature of your disability.
C. Individuals Covered -
List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
NOTE: Enter Domestic Partner ONLY if your employer has elected that coverage.
NOTE FOR MEDICAL AND DENTAL COVERAGE: While the Federal Patient Protection and Affordable Care Act mandates coverage of dependent children up to age 26,
your plan may allow coverage beyond age 26. Some exceptions apply. Please refer to your plan documents or contact your benefits administrator.
Primary Office
Dental Office
Birthdate
Coverage
Social Security
ID Number
ID Number
Sex
Name (Last, First, M.I.)
Number
(MM/DD/YYYY)
Election
M/F
(if applicable)
(if applicable)
Employee
Yes
Yes
Yes
Yes
Yes
Yes
Medical
Dental
N/A
N/A
1.
Life/Dis
Spouse
Domestic Partner
Medical
N/A
N/A
Dental
2.
Life
Child
Medical
Dental
3.
Life
Child
Medical
Dental
4.
Life
Child
Medical
Dental
5.
Life
Child
Medical
Dental
6.
Life
1
GR-67834-2 (3-11)
TX - SGB R-POD I

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