Enrollment/Change Form
New & Existing Groups
P 888.313.7277
F 888.354.7277
Medical
Life/ADD/LTD
A.
_____/_____/_______
Enrollments/Additions
Enroll in:
Dental
ID Theft
Requested Effective Date
(Complete A, E, F, N, O)
(Select all that apply)
Vision
(1
st
of month only other than birth)
(Select Coverages G-M)
Open Enrollment/Renewal
New Hire
Re-hire
Reason:
Add Dependent
Status Change
Involuntary Loss of Coverage
Date of Birth:
____/____/_____
(Part to Full-time)
Other _______________________________
(Select One)
Date of Marriage: ____/____/_____
____/____/_____
Adoption
(requires legal documentation)
The following documents are required and must be submitted within 30 days of an associated qualifying event:
HIPAA Certificate if enrolling due to loss of coverage; Marriage Certificate if enrolling a spouse due to a qualifying event; Birth Certificate if adding a dependent child; Declaration of Cohabitation & Financial
Interdependence Form if enrolling a domestic partner due to a qualifying event. Note: Additional documentation may be required.
Covered elsewhere?
____/____/____
Medical
Y N
B.
Waive Coverage
Waive coverages:
Requested Date to Waive Coverage
Dental
Y N
(Select One)
(Complete B, E, N, O)
(1
st
of month only)
Vision
Y N
C.
Change
Name Change
Address Change
Change Type:
Requests
____/____/____
Other: _____________________________
(Select One)
Requested Effective Date
(Complete C, N, O)
(List changes in E, F)
Requested Termination Date (must be the
Medical
Dental
Vision
Life/ADD/LTD
ID Theft
__/__/__
last day of a month)
Employee
Employee
Employee
Employee
Employee
D.
Spouse
Spouse
Terminations
Reason:
Spouse
Spouse
Spouse
Child(ren)
Child(ren)
Child(ren)
Child(ren)
Child(ren)
1
1
1
1
1
No Longer Employed
(Complete D, E, F
, N, O)
1
Cancel Coverage
Other_____________
Indicate the coverages and members to terminate above.
If terminating coverage for one or more child(ren)on the policy (but not all), list in Section F the child(ren) who should have their coverage terminated. If no
1
child(ren) are separately listed in Section F, all dependent children on the policy will be terminated.
E.
Employee Information
Group Name
Hire Date* (MM/DD/YYYY)
Prefix
First Name*
Middle Initial
Last Name*
Suffix
Social Security #*
Date of Birth* (MM/DD/YYYY)
Male
Divorced
Legally Separated
Single
Gender*:
Marital Status:
_____/_____/________
Female
Domestic Partner
Married
Widowed
Address*
Apt
City/State/Zip*
County
Home Phone
Cell Phone
Home Email
Home
Work Phone/Ext
Work Email
Preferred Email:
Work
F.
Dependent Demographics
Dependent 1
Prefix
First Name*
Middle Initial
Last Name*
Date of Birth* (MM/DD/YYYY)
Social Security #*
_____/_____/________
Male
Disabled?
Yes
Divorced
Legally Separated
Single
Gender*:
Marital Status:
Female
No
Domestic Partner
Married
Widowed
)
(Requires Additional Documents
Spouse
Child
Relationship*:
Domestic Partner
Domestic Partner Child
Dependent 2
Prefix
First Name*
Middle Initial
Last Name*
Date of Birth* (MM/DD/YYYY)
Social Security #*
_____/_____/________
Male
Disabled?
Yes
Divorced
Legally Separated
Single
Gender*:
Marital Status:
Female
No
Domestic Partner
Married
Widowed
)
(Requires Additional Documents
Spouse
Child
Relationship*:
Domestic Partner
Domestic Partner Child
Dependent 3
Prefix
First Name*
Middle Initial
Last Name*
Date of Birth* (MM/DD/YYYY)
Social Security #*
_____/_____/________
Male
Disabled?
Yes
Divorced
Legally Separated
Single
Gender*:
Marital Status:
Female
No
Domestic Partner
Married
Widowed
)
(Requires Additional Documents
Spouse
Child
Relationship*:
Domestic Partner
Domestic Partner Child
*
REQUIRED FIELDS
V1 of 1 9/2017