Fillable Disability Enrollment/change Request - Aetna printable pdf download

Disability Enrollment/Change Request

Aetna Life Insurance Company

A. Transaction Information -

Based on the requirements of your plan, you may be required to submit evidence of good health.

Short Term Disability

Long Term Disability

Indicate transaction below.

Effective Date (MM/DD/YYYY)

Add Coverage

Terminate Coverage (Cancel)

Add Coverage

Terminate Coverage (Cancel)

Increase Coverage

Date of Hire (MM/DD/YYYY)

Indicate Plan Name

Decrease Coverage

Indicate Plan Name

ndicate Plan Name

B. Employer Information -

Please Print all Information

2. Control No.

1. Employer Name - Full Name of Business or Organization

Suffix

Account

3. Plan Number

4. SFO

5. Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization

6. Claim Office Code 7. Customer Code (Optional)

C. Employee Information -

Please Print all Information

1. Employee Social Security Number

2. Employee Name (Last, First, M.I.)

3. Birthdate (MM/DD/YYYY)

4. Sex

5. Telephone Numbers

Home

Work

(

)

(

)

6. Employee Home Address (Number, Street, Apt. No., City, State, ZIP Code)

7. Employee Annual Earnings

8. Occupation/Title

9. Work State

D. Certification -

Signatures Required

I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that this insurance is subject to all of the terms of the Plan of Insurance contained in the

group policy and summarized in the announcement material provided me and the certificate issued to me. I understand that the effective date of insurance for myself or for any of my dependents is subject

to my being actively at work on that date and that the effective date of insurance for any of my dependents is also subject to the dependent health condition requirements of the Plan. Further, I understand

that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its written consent.

I understand that, in the event I fail to sign this form within 31 days of the effective date of eligibility or that for any reason Aetna does not receive notice of the Enrollment/Change Request within a

reasonable time following the event, my and my dependents' eligibility may be affected. I request my employer to arrange for the issuance of Group Disability Coverage for which I am or may become

eligible and authorize deductions of the required contributions from my earnings.

Misrepresentations: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false

information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil

penalties.

Attention California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any insurance company files a

statement of claim containing any materially false or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison, and substantial civil penalties. Many other states

have similar laws.

Attention Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance proceeds must be reported to the

Insurance Division.

Attention Florida and Virginia Residents: Any person who knowingly and with intent to defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or

misleading information is guilty of a felony of the third degree.

Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any

materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to

criminal and civil penalties.

My signature below signifies my agreement with the statements and authorization above.

Date

Employee Signature (Required)

Employer Signature (Required)

Date

Employee E-mail Address

Name (please print)

Title

Please make a copy for your records.

visit us at

GR-67269-92 (12-01)