Form Gg-013374/d/v - Enrollment/change Form - Dental/vision - 2001
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1
2ENROLLMENT/CHANGE FORM
Please Print clearly and in Black or Blue ink
Please Print in Capital Letters only
DENTAL/VISION
*
*
Planholder Name (Company Name)
Group Plan Number
Division Class
PLEASE CHECK APPROPRIATE BOX
Initial Enrollment/Refusal of Coverage
Add Employee/Dependents
Drop/Refuse Coverage
Information Change
(Complete Sections 1, 3, 4, 6)
(Complete Sections 1, 3, 5, 6)
(Complete Sections 2, 4, 6)
(Complete Section 6)
S
S
(The date of withdrawal cannot be prior to the date this form is completed and signed.)
Add Employee
Add Spouse
Add Children
E
E
Drop Employee (Complete Section 4)
Drop Dependents (Complete Section 4)
Newborn
C
C
Termination of Employment *
New Hire
Marriage Date _____ /_____ /_____
T
T
Last Day of Coverage _____ /_____ /_____
Previously refused this coverage
I
I
Retirement *
Previously refused this coverage
Previously refused this coverage
Adoption Date _____ /_____ /_____
O
O
*Last Day Worked _____ /_____ /_____
Loss of Other Coverage
Loss of Other Coverage
Loss of Other Coverage
N
N
*Last Day of Coverage _____ /_____ /_____
(Complete Section 5 if applicable)
(Complete Section 5 if applicable)
(Complete Section 5 if applicable)
Other __________________________________________________________________
1
2
SELECT COVERAGE(S):
REFUSE/DROP COVERAGE(S):
LOSS OF OTHER COVERAGE:
Dependents cannot be enrolled for
(See Refusal on back)
coverage refused by the employee.
I and/or my dependents were previously covered under
S
S
S
Dental
Spouse
Child(ren)
Employee
another group plan. Loss of coverage was due to:
E
E
E
Vision
C
Dental
C
Employee
Spouse
Child(ren)
C
Spouse
Child(ren)
Employee
Termination of Employment
T
T
T
______ /______ /______
I have been offered the above coverages and wish to refuse/
I
I
I
(
)
drop enrollment for the following reasons:
Select
lndemnity
PPO
Buy-Up
Divorce
O
O
O
______ /______ /______
N
One
N
N
Pre-Paid ** (Complete Pre-Paid Office # in Section 6)
Covered under another insurance plan
Death of Spouse
______ /______ /______
3
4
5
Other ______________________________________
Vision
Employee
Spouse
Child(ren)
Term./Expiration of Coverage
______ /______ /______
(additional information may be required)
Pre-Paid Office #
Last
First
MI Sex
Birth Date
Social Security Number
(MM DD YYYY)
(See directory)
Add Drop
Employee
M F
-
-
-
-
Name
Street address
City
State ZIP
Marital Status:
Single
Married
Divorced
Legally Separated
Widowed
S
Home Phone: (
)
-
E
Are you: Actively at work
Occupation/Job Title:
Retired
Other _________ (additional information may be required)
C
Date of Full Time Hire
Number of hours worked per week:
(MM DD YYYY):
-
-
T
I
Pre-Paid Office #
Last
First
MI Sex
Birth Date
Social Security Number
Student
(MM DD YYYY)
(See directory)
Add Drop
O
Spouse
M F
-
-
-
-
N
Name
Child
M F Y N
-
-
-
-
6
Name
Child
M F Y N
-
-
-
-
Name
Child
M F Y N
-
-
-
-
Name
Child
M F Y N
-
-
-
-
Name
A)
Have you included stepchildren?
Yes
No Are they dependent upon you for support and maintenance? Yes
No
B)
Is this your first eligible child?
Yes
No
If "no," please list all eligible children above.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of
insurance fraud. The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form which I have read and understand.
-
-
Signature: __________________________________________________________________
Date
(MM DD YYYY)
GG-013374/D/V 8/01
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