Form Tx-72000 - Humana Employee Enrollment Form - 2-99 Employees - 2008
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Humana Employee Enrollment Form - 2-99 Employees
TEXAS
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.
PPO and Classic Medical plans, Life and Vision plans insured or administered by Humana Insurance Company. HMO plans offered by Humana Health Plan of
Texas, Inc., a Health Maintenance Organization. POS plans offered by Humana Health Plan of Texas, Inc., a Health Maintenance Organization and insured or
administered by Humana Insurance Company. Prepaid and AdvantagePlus dental benefits offered and administered by DentiCare, Inc. (d/b/a CompBenefits).
All other Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company. CompBenefits Vision plan insured and
administered by CompBenefits Insurance Company.
Please print clearly and fill in each applicable circle.
Proposed Effective Date: _ _ / _ _ / _ _ _ _
Company name
Company city
State
Enrollment Information
Height
Weight
Full-time
Disabled?
Relationship
Last name, First name MI
Gender
student?
Date of birth
If yes, indicate reason.
(ft / in)
(lbs.)
Reason:
m F
m N
Employee
/
_ _ / _ _ / _ _ _ _
N/A
m M
m Y
Reason:
m F
m N
Spouse
/
_ _ / _ _ / _ _ _ _
N/A
m M
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Other (specify):
Reason:
m F
m N
m N
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
EMPLOYEE INFORMATION:
HOURS WORKED PER WEEK:
DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _
m RETIREE
SSN #
Street address
APT / Suite / Box
City
State
Zip code
Phone # (
)
Language: m English m Spanish
Email address
Do you have a disability that affects your ability to communicate or read? m N m Y
TX-72000-EI 5/2008
Medical
Group #:
Benefit #:
Class/Div:
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
1. Prior medical coverage during the past 18 months (individual or other group coverage)?
m N m Y
Prior medical insurance carrier name Policy #
Prior coverage type:
Effective date _ _ / _ _ / _ _ _ _
m Employee only
m Employee and spouse
Term date _ _ / _ _ / _ _ _ _
m Employee and child(ren) m Family
2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)?
m N m Y
Other Medical Insurance carrier name Policy #
Other coverage type:
Effective date _ _ / _ _ / _ _ _ _
m Employee only
m Employee and spouse
Term date _ _ / _ _ / _ _ _ _
m Employee and child(ren) m Family
3. Medicare coverage:
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
Employee coverage: m N m Y
Medicare ID
Medicare ID
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
Spouse coverage:
m N m Y
TX-72000-MD 5/2008
Health Savings Account
Group #:
Benefit #:
Class/Div:
If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details.
Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can find additional information on
HSAs on . Select the Quick Link for Spending Account information on the Member page.
Do you elect the Health Savings Account?
Beneficiary for this account will be the employee’s estate. You may change beneficiary information
m N m Y (If no, complete waiver.)
on file with the bank that administers the HSA once the account is established.
TX-72000-HA 5/2008
TX-72000 5/2008
1
Reorder# TX-51340-SB 11/2008
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