Fillable Form Gr-69209-14 - Ohio Employee Enrollment/change Form

NOTE: Before you return this form to your employer, you may wish to tape or staple the form so that health information is not

visible. This will help keep your health information private.

Ohio Employee Enrollment/Change Form

(For groups with 51 to 100 employees)

Aetna Life Insurance Company

Aetna Health Inc.

Aetna Health Insurance Company

Aetna Open Choice

PPO plans, Aetna Indemnity plans and Aetna Vision

Preferred plans are underwritten by Aetna Life Insurance

Company. Aetna HMO plans are underwritten by Aetna Health Inc. Aetna Health Network Option plans are underwritten by Aetna Health

Insurance Company and Aetna Health Inc. Aetna Savings Plus plans are underwritten by Aetna Health Inc., Aetna Life Insurance Company

and Aetna Health Insurance Company. Dental plans are provided or administered by Aetna Life Insurance Company. Vision insurance plans

are underwritten by Aetna Life Insurance Company. For Vision coverage, certain claims administration services are provided by First

American Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care, LLC (“EyeMed”).

Group number

INSTRUCTIONS: You must complete this enrollment form in full. If you do not, we will return it to you, and

that can delay its processing. You alone are responsible for its accuracy and completeness. If you are

Aetna member ID number (if available)

declining coverage, you must complete Section G. Please use only black ink to complete this form.

Company name:

Effective date

New hire

Add spouse

Employee termination date:

Rehire / reinstatement

Add domestic partner

Remove spouse

New group enrollment

Add dependent child

Date of hire

Remove domestic partner

Late enrollment

Change of coverage

Remove dependent child

Name change

Waiver

Benefit waiting period*

Cancel coverage

Open enrollment

Class 1

Class 2

Other

Loss of coverage

* Only required when your employer

has 2 benefit waiting periods

COBRA

State continuation for:

Employee

Dependent

Length of continuation:

18 months

36 months

Other

Qualifying event

Original qualifying event date

Loss of coverage date

A. Employee information -

You must complete this section.

Social Security number

Last name, first name, middle initial

Job title

Home address

Apt. number City, state

ZIP code

Work address

City, state

ZIP code

Home telephone

Work telephone

Primary language spoken

Number of dependents, including spouse,

(optional)

or domestic partner, enrolling for medical

(

)

(

)

coverage

Salary (if enrolling for life or

Number of hours

Check one:

Hourly

worked a week

disability coverage)

Full time

1099

Seasonal

COBRA

Weekly

Part time

Retiree

Temporary

Union

Monthly

B. Coverage selection

– Please print clearly. (Top boxes for employer/Aetna-use only.)

Control/Group number

Suffix

Account

Plan number

Class code

1. Medical

Yes

To enroll, check one and enter the plan option elected following the plan type below.

Health Network Option

– Plan option:

Savings Plus – Plan option:

HMO – Plan option:

Open Choice

PPO – Plan option:

Indemnity:

Other:

Continued on next page

OH R-POD

GR-69209-14 (4-16)

Form Gr-69209-14 - Ohio Employee Enrollment/change Form - Aetna

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