Fillable Form Nj Hint - Aetna Enrollment/change Nj 101 Or More Employees (Page 3 of 4) in pdf

Conditions of Enrollment

Applicant Acknowledgments and Agreements

On behalf of myself and the dependents listed in Section D, I agree to or with the following:

1. a) I authorize the sources stated below to give to Aetna Life Insurance Company or any consumer reporting agency acting on its behalf, information about

me and my minor children, if applying for coverage. Such information will pertain to employment, other health coverage, and medical advice, treatment

or supplies for any physical or mental condition. Authorized sources are any physician or medical professional; any hospital, clinic or other medical

care institution; any carrier; any consumer reporting agency; any employer. Please note that a consumer report includes information regarding

the enrollee’s character, general reputation, personal characteristics, and mode of living. If you would like a copy of your consumer report

obtained by Aetna, you may contact Member Services. Aetna will provide a copy of the report upon request.

b) I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which Aetna Life Insurance

Company has taken in reliance on the authorization. I understand this authorization will not be valid after 30 months, if not revoked earlier.

c) I know that I have a right to receive a copy of the authorization if I request one.

d) I agree that a photocopy of this authorization is as valid as the original.

2. I acknowledge by enrolling in an Aetna plan, coverage is provided by Aetna Life Insurance Company in accordance with the contract.

3. Enrollment of myself and of the listed dependents into the plan is effective on acceptance by Aetna Life Insurance Company.

4. Coverage and benefits are contingent on timely payment of premiums and may be terminated as provided in the plan documents. My employer is hereby

authorized to withhold payments from my wages, as appropriate.

Misrepresentation

5. Any person who includes any false or misleading information on an Enrollment/Change Request Form for a health benefits plan is subject to criminal and

civil penalties.

J. Employee Signature

I represent that all the information supplied in this application is true and complete to the best of my knowledge and belief. I hereby agree to the conditions of

enrollment contained in this Enrollment/Change Request form. I authorize deductions from my earnings for any required contributions.

Employee Signature - Required

Employee E-mail Address (optional)

Date (Month/Day/Year)

K. Employer Verification

– To be completed by Employer

Employer Signature – Required

Title

Date (Month/Day/Year)

Employee copy may be used as temporary ID card for 30 days from the effective date if authorized by employer. Coverage must be verified with Aetna Life

Insurance Company prior to visiting a specialist or admission to a hospital.

Please make a copy for your records.

Visit us at

GR-67820-2 (2-14) NJ Traditional G

NJ HINT - Group