Fillable Form Nj Hint - Aetna Enrollment/change Nj 101 Or More Employees (Page 2 of 4) in pdf

D. Individuals Covered -

List individuals for whom you are enrolling or adding/changing/removing coverage. Attach additional sheets if necessary.

NOTE: 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

ID Number

Birthdate

(if applicable)

Sex

Social Security

Last Name, First Name, M.I.

Number

DD YYYY

M/F

NPI Number

1. Employee

Yes

Office

N/A

NPI

2. Spouse/Civil Union/Domestic Partner

Office

N/A

NPI

3. Child

Office

NPI

4. Child

Office

NPI

E. Race/Ethnicity – Optional

(This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)

Employee

Child

White – 01

African American or Black – 02

White – 01

African American or Black – 02

Hispanic or Latino – 03

Asian – 04

Other – 05

Hispanic or Latino – 03

Asian – 04

Other – 05

Spouse/Civil Union/Domestic Partner

Child

White – 01

African American or Black – 02

White – 01

African American or Black – 02

Hispanic or Latino – 03

Asian – 04

Other – 05

Hispanic or Latino – 03

Asian – 04

Other – 05

F. Declination/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.

Coverage Declined for:

Myself

Dependents

Spouse/Civil Union/Domestic Partner

Reason for Declining Coverage (If applicable, please attach front/back of your health coverage ID card.):

Covered by Spouse/Civil Union/Domestic Partner's group coverage - Carrier Name and ID Number

Enrolled in other Insurance Plans – Insurance Company Name and ID:

Medicare

Covered by TRICARE or CHAMPVA

Other (Explain):

Spouse/Civil Union/Domestic Partner covered by employer’s group medical coverage

I was given the opportunity to enroll in the medical plan offered by my employer and underwritten by Aetna Life Insurance Company; however, I refuse the

above coverage(s). By declining this group coverage I acknowledge that I and/or my dependents may have to wait until the plan's next anniversary date to be

enrolled for group coverage.

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

Date (Month/Day/Year)

Employee Signature

G. Dependent Information

Does any dependent listed in Section D live at another address?

Yes

If any dependent's last name differs from yours, explain the circumstances.

If Yes, who and what address?

H. Other Insurance

If you have checked Yes to Other Health or Rx Drug Coverage (Section C), provide name and policy number of insurance carrier, HMO, or other source, a copy of the insurance card,

and start date of the coverage.

No If Yes, provide name and address of Spouse’s/Civil Union/Domestic Partner’s employer.

Is your Spouse/Civil Union/Domestic Partner employed?

Yes

Name of Covered Individual

Carrier Name

Group Number

Start Date

Termination Date

Health

Yes

If you have questions concerning the benefits and services provided by or excluded under this Plan, contact a Member Services representative at