Employee Enrollment Form
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CA Key Accounts
Employee Enrollment Form
UnitedHealthcare Insurance Company
UnitedHealthcare of California
To speed the enrollment process, please be thorough and
fill out all sections that apply.
Requested Effective Date of Coverage/Date of Change ___/___/___
To Be Completed by Employer
Group Name: __________________________________________________________________ DBA (if applicable):____________________________________
Product
Group #
Plan Variation #
Reporting Code
Date of Hire _______/_______/_______
Medical
Position/Title
Dental
Hours Worked per Week
Vision
Reason for Application
Employee Type (Check all that apply)
Cancellations: Last Date of Employment __/__/__
Active
Union
Non-Union
Retired
New Group Plan
New Hire
Requested Effective Date of Cancellation __/__/__
Hourly
Salary
Other _______
Cancel all coverage
Life Event/Date__/__/__
Annual
Early Retiree
Cancel all listed below – Section B (family information)
Open
Status Change _______
COBRA
Cal COBRA
Enrollment
Death
Employee Terminated
Divorce
Dependent Add/Delete
Start date___/___/___ End date___/___/___
Late
Moved out of service area
Change Name/Address
Indicate Qualifying Event ______________
Enrollee
Dependent reached max age
Other ______________
Original Qualifying Event Date
Rehire
Other (describe)__________________________
Begin date ___/___/___ End date___/___/___
Complete all sections. If you are waiving all coverage, please
A. Employee Information
complete only Sections A and F.
Last Name
First Name
MI
Social Security Number
Home Phone
Work Phone
Address
Apt. #
City
State
ZIP
E-mail address
Date of Birth
Sex
Marital Status
Have you or your dependents ever been a
Preferred Language:
M
Single
Married
Divorce
UnitedHealthcare member?
Yes
No
English
Spanish
Chinese
Vietnamese
F
Widowed
Domestic Partner
Korean
Other _________________
Primary Care Physician
Name: ________________________________________________________
Primary Care Dentist
Name_____________________________
(1)
(2)
Address ____________________________________________________________________________
ID#__________________________________
ID# ___|___|___|___|___|___|___|___|___|___
Existing Patient
Existing Patient
Yes No
Yes No
Have you used tobacco within the past 12 months?
Yes
No
Complete all sections for all family members.
B. Family Information
Name (Last, First, MI)
Sex
Relationship
Birth Date
Used tobacco
Check
(4)
Appropriate
within the last
M
Spouse/
Box
12 months?
____/____/____
F
Social Security Number
Domestic
Enroll
Yes
No
Partner
____|____|____|-|____|____|-|____|____|____|____|
Cancel
Address (if different from Employee)
Preferred Language:
English
Spanish
Chinese
(3)
Change
Vietnamese
Korean
Other_________________
Primary Care Physician
Name: ________________________________________________
Primary Care Dentist
Name_____________________________
(1)
(2)
Address ____________________________________________________________________
ID#__________________________________
Existing Patient
ID# ___|___|___|___|___|___|___|___|___|___
Existing Patient
Yes No
Yes No
IMPORTANT: (1) Please use the UnitedHealthcare Provider Directory to select a Primary Care Physician for yourself and each of your covered dependents for products
requiring a Primary Care Physician designation. (2) Please use the Dental Directory to select a Primary Care Dentist for yourself and each of your covered dependents for
products requiring a Primary Care Dentist designation. (3) Include address only if different from Employee. (4) For court-ordered dependent, legal documentation must
be attached. (5) If you answered “Yes” for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly dependent upon subscriber/covered person
for support and is not able to be self-supporting because of a physically or mentally disabling injury, illness or condition, please attach a medical certification of disability.
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LG.EE.12.CA 9/12
400-3689 3/14
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