Form Nj Hint - Aetna Enrollment/change Nj 101 Or More Employees
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4New Jersey
Employee Enrollment/Change Request
For Employer Groups with 101 or More Employees
Aetna Life Insurance Company
Member Aetna ID Number (if available)
Aetna plans are underwritten by Aetna Life Insurance Company.
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 C and F.
A. Type of Activity –
To Be Completed by Employer. To Add, Change, or Remove coverage for dependents over the limiting age, but less than 31, Aetna Form
HINT Supplemental Enrollment Information Form Implementing P.L. 2005, c. 375, must be completed. Refer to instructions on Page 4 before completing this
form.
Please Print clearly.
1. Enrollment
2. Change
– Check all that apply.
Date of Event
Reason
Effective Date
New Hire
Change of Coverage
/
/
/
/
Rehire/Reinstatement
Add Spouse/Civil Union/
/
/
New Group Enrollment
Date of Hire
Domestic Partner/Dependent
Child
/
/
Late Enrollment
Name Change
/
/
Other
Other
/
/
Add/Change Primary Office ID
/
/
Number or NPI Number
NOTE: Employee must be enrolled for spouse/civil union/domestic partner/dependent(s)
to have coverage.
3. Remove or Terminate
– Check all that apply.
4. Continuation of Coverage, i.e., COBRA, State, Total Disability
- Not all options are available or applicable. Contact Employer for available
Effective Date
Reason
options.
Employee Termination
/
/
COBRA
State Continuation
Total Disability
Remove Spouse/Civil Union/
/
/
Coverage for:
Domestic Partner/
Employee
Spouse/Civil Union/Domestic Partner*
Dependent(s)
Dependent Child*
Length of Continuation:
18 mos.
29 mos.
36 mos.
Cancel Coverage
/
/
Total Disability – Attach proof of total disability
NOTE: Employee must be enrolled for spouse/civil union/domestic partner/
Date of Loss of Coverage:
/
/
dependent(s) to have coverage.
Date of Qualifying Event:
/
/
Reason:
* Please complete Add/Change/Remove and Name columns in Section D.
*Civil Union/Domestic Partners are ineligible to make an election for COBRA
continuation.
B. Medical Plan Options –
Your selection must be offered by your employer.
Control/Group No.
Suffix
Account
Plan No.
Class Code
Check One.
®
Managed Choice
POS – Plan Option:
®
Aetna Choice
POS II – Plan Option:
Aetna HealthFund™ – Plan Option:
®
Aetna Open Access
Managed Choice – Plan Option:
®
Open Choice
PPO – Plan Option:
®
Traditional Choice
– Plan Option:
Other – Plan Option:
C. Employee Information
- Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Home Telephone
Primary Language Spoken
(Optional)
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Work Telephone
No. of Hours Worked Per Week
Check One:
Marital Status
No. of Dependents Including
Spouse/Civil Union/ Domestic Partner
Full-Time
1099
Seasonal
COBRA
Married
Civil Union Partner
Part-Time
Retired
Temporary
Union
Single
Domestic Partner
1
NJ Traditional
R-POD G
NJ HINT - Group
GR-67820-2 (2-14)
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