Application For Enrollment Form printable pdf download

COMMERCIAL (GUAM/CNMI)

Choose one Medical Plan:

Choose one Option:

Choose one Class:

GOLD PLAN

BASIC

OTHER

MEDICAL ONLY

CLASS I – Single

SILVER PLAN

CW 80/20

MEDICAL & DENTAL

CLASS II – Couple

BRONZE PLAN

NRCW 100

CLASS III – Family

LAST NAME

FIRST NAME

M.I.

MAILING ADDRESS

SEX

MARITAL STATUS

DATE OF BIRTH (MM/DD/YY)

SOCIAL SECURITY NUMBER

HOME PHONE

WORK PHONE

OTHER CONTACT NUMBER

EMAIL ADDRESS

(INCLUDE EXT.)

EMPLOYER

DATE OF EMPLOYMENT

PROBATION PERIOD

(CONTRACT WORKER? YES or NO)

NONE

30 DAYS

60 DAYS

90 DAYS

OTHER ____________________

SPOUSE’S NAME

SPOUSE’S EMPLOYER

SPOUSE’S CONTACT NUMBER(S)

LIST ALL MEDICAL INSURANCE COVERAGE WITHIN THE LAST 12 MONTHS (Including Medicare/Medicaid/MIP)

NAME OF INSURANCE

NAMED OF INSURED

GROUP or INDIVIDUAL

EFFECTIVE DATE

TERMINATION DATE

LIST ALL FAMILY MEMBERS YOU WISH TO ENROLL

SOCIAL SECURITY

SEX

RELATIONSHIP

LAST NAME

FIRST NAME

M.I.

BIRTHDATE

NUMBER

SPOUSE

I hereby authorize my employer to deduct from my paycheck any required contribution for group benefits for which I am eligible and to release any

information regarding payment and leave status in order to facilitate medical services I might require. I agree that I shall abide by the provisions of coverage

of the Group Plan Certificate under which I am enrolled. I understand that it is my responsibility to report any changes in the eligibility of my dependents. I

further understand that newly eligible dependents may only be added with 30 days from becoming eligible or during a special enrollment or during the open

enrollment period of my group. I (and my dependents) hereby authorize any medical health care provider or facility that has any records or knowledge of me

(us) or my (our) health to give StayWell any such information. A photographic copy of this authorization shall be valid as the original. I UNDERSTAND

THAT ANY CLAIMS ASSERTED BY ME OR MY DEPENDENTS AGAINST STAYWELL, ITS EMPLOYEES OR AGENTS, WHETHER BASED IN

CONTRACT, TORT OR OTHERWISE (INCLUDING PROFESSIONAL LIABILITY), ARE SUBJECT TO BINDING ARBITRATION. I have read a copy of the

brochure which contains the benefits, limitations and exclusions applicable to my health care plan. I understand that the coverage for which I am eligible will

be further explained, UPON REQUEST, by a StayWell representative or my personnel officer. I understand that StayWell has the right to request for

additional documents as needed to determine eligibility.

EMPLOYEE’S SIGNATURE

DATE SIGNED

FOR OFFICE USE ONLY

ENROLLMENT

CUSTOMER CARE

MARKETING

NOTES

GROUP NO.:

Received by:

Representative: