Eligibility Enrollment/Update
Check:
Indiana
Michigan
North Carolina
Ohio
–
Client Name: ____________________________________________
Client#/Subclient#
ABCDEF1 2 4
3 5 6
Subscriber Information
(please complete for all enrollments/updates:) Example:
Subscriber Name (Last)
(First)
(M.I.)
Sex
Status*
Active
COBRA
Male
Retiree
Surviving
Female
Subscriber Social Security Number
Birth Date
Coverage Effective Date
Hire Date
–
–
–
–
–
–
–
–
Street Address
Email
Check here if this
is a new address
City
State
ZIP Code
–
Plan Enrollment/Update Information
(please indicate type of update and fill in appropriate information):
Type of Update:
New Enrollment
Reinstatement
Change/Correction to Information
Termination of Benefits
Waive Benefits
Group Transfer
Rate Code Change*
Change is for:
From: Client/Subclient#
To: Client/Subclient#
From:
To:
Effective Date of Change
Subscriber
Dependent
–
–
–
–
Enrollment/Corrections to Information
(please fill in for spouse/dependents for first-time enrollment or corrections):
SPOUSE Name (Last)
(First)
(M.I.)
Sex
Male
Female
Social Security Number
Birth Date
Status*
–
–
–
–
Legal
Surviving
DEPENDENT #1 Name (Last)
(First)
(M.I.)
Sex
Male
Female
Social Security Number
Birth Date
Status*
–
–
–
–
IRS Dep.
Surviving
Disabled
Sponsored
DEPENDENT #2 Name (Last)
(First)
(M.I.)
Sex
Male
Female
Social Security Number
Birth Date
Status*
–
–
–
–
IRS Dep.
Surviving
Disabled
Sponsored
DEPENDENT #3 Name (Last)
(First)
(M.I.)
Sex
Male
Female
Social Security Number
Birth Date
Status*
–
–
–
–
IRS Dep.
Surviving
Disabled
Sponsored
DEPENDENT #4 Name (Last)
(First)
(M.I.)
Sex
Male
Female
Social Security Number
Birth Date
Status*
–
–
–
–
IRS Dep.
Surviving
Disabled
Sponsored
*See reverse side for instructions and explanation of codes.
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
_________________________________________
_________________________
1
Subscriber’s Signature
Date
314-55
(10-15)