A
P
P
L
I
C
A
T
I
O
N
F
O
R
E
N
R
O
L
L
M
E
N
T
A
P
P
L
I
C
A
T
I
O
N
F
O
R
E
N
R
O
L
L
M
E
N
T
N
E
W
E
N
R
O
L
L
M
E
N
T
N
E
W
E
N
R
O
L
L
M
E
N
T
COMMERCIAL (GUAM/CNMI)
C
C
H
H
A
A
N
N
G
G
E
E
O
O
F
F
S
S
T
T
A
A
T
T
U
U
S
S
T
O
A
D
D
D
E
P
E
N
D
E
N
T
T
O
A
D
D
D
E
P
E
N
D
E
N
T
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
M
F
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:
UNDERWRITING
ENTERED:
Effective Date:
Reviewed by:
EFF. DATE:
Reviewed by:
SW-APP 02/12