Form Gr-67834-20 - Aetna Enrollment Change Request Form Page 3
Download a blank fillable Form Gr-67834-20 - Aetna Enrollment Change Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gr-67834-20 - Aetna Enrollment Change Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Instructions
Employer
Complete the Employer Group Information in the upper right corner of the form.
•
• Section A - Type of Activity: Check box(es) indicating reason(s) for submitting application.
• Complete Section I - Employer Verification at the bottom of Page 2.
• Employer must complete this section for all new enrollments, coverage changes and terminations.
• Employer must sign and date the enrollment/change request in order for it to be processed.
Employee
- Complete Sections B - H.
Section B - Employee Information:
Complete all information in order for your application to be processed. If employee is declining coverage, complete Sections B
and G.
Section C - Plan Option:
• Check one plan option box for Life/Disability selection and/or enter plan number and name for Dental selection (if applicable).
• Select only an option offered by your employer.
• Please fill out complete name of Beneficiary: First, Middle Initial, Last. Fill in Social Security Number and Relationship.
Section D - Individuals Covered:
• Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an
individual.
• Print your full name along with the name(s) of your dependent(s), if applicable. Indicate Sex, Birthdate, and Social Security
Number for each individual listed.
• If a dependent is a full-time college student, you must attach a current course schedule or a letter from the school confirming
full-time student status (12 or more credits).
Section E - Other/Previous Coverage:
Complete this section for all new enrollments or coverage changes.
Section F - Dependent Information:
Complete this section for all new enrollments or coverage changes.
Section G - Declination/Waiver of Coverage:
Complete this section if declining coverage for any eligible employee and/or their eligible family members. Employee must sign
and date; a witness must sign and date.
Section H - Employee Signature:
• Complete this section for all new enrollments, coverage changes and terminations.
• Employee must sign and date the enrollment/change form in order for it to be processed.
Section I - Employer Verification:
• Employer must complete this section for all new enrollments, coverage changes and terminations.
• Employer must sign and date the enrollment/change form in order for it to be processed.
Conditions of Enrollment
Applicant Acknowledgments and Agreements
On behalf of myself and the dependents listed on the reverse side, I agree to or with the following:
1. a) I authorize the sources stated below to give to Aetna Life Insurance Company and/or Aetna Dental Inc., 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. Authorized sources are: any carrier; any consumer reporting agency; any
employer.
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 and/or Aetna Dental Inc. 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 this 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 Life Insurance Company and/or Aetna Dental Inc. plans, coverage is provided by
Aetna Life Insurance Company and/or Aetna Dental Inc. 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
and/or Aetna Dental Inc.
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 application for an insurance policy is subject to criminal
and civil penalties.
3
GR-67834-20 (7-08)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business