Form (Nf) Az-72000 - Humana Employee Enrollment Form - 2008
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Humana Employee Enrollment Form - 2-50 Employees & Standard Saver PPO
ARIZONA
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.
HMO and Freedom plans offered by Humana Health Plan, Inc. POS plans offered by Humana Health Plan, Inc. and insured or administered by Humana
Insurance Company. PPO, Standard PPO, Classic medical plans and Life plans insured or administered by Humana Insurance Company. Standard Saver PPO
medical and HDHP PPO plans insured or administered by Emphesys Insurance Company. Dental Prepaid plans underwritten by Employers Dental Services. All
other Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company. Vision plans insured and administered by
Humana Insurance Company or CompBenefits Insurance Company.
PLEASE COMPLETE AND ATTACH THE UNIFORM EMPLOYEE HEALTH STATUS QUESTIONNAIRE WITH THIS APPLICATION.
Please print clearly and fill in each applicable circle.
Proposed effective date: _ _ / _ _ / _ _ _ _
Company name
Company city
State
Enrollment Information
AZ-72000-EI
3/2008
Height
Weight
Full-time
Disabled?
Relationship
Last name, First name MI
Gender
student?
Date of birth
If yes, indicate reason.
(ft / in)
(lbs.)
Reason:
m F
m N
Employee
/
N/A
_ _ / _ _ / _ _ _ _
m M
m Y
Reason:
m F
m N
Spouse
/
N/A
_ _ / _ _ / _ _ _ _
m M
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
Reason:
m F
m N
m N
Child
_ _ / _ _ / _ _ _ _
/
m M
m Y
m Y
Other (specify):
Reason:
m F
m N
m N
/
_ _ / _ _ / _ _ _ _
m M
m Y
m Y
EMPLOYEE INFORMATION:
HOURS WORKED PER WEEK:
m RETIREE
DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _
SSN #
Street address
APT / Suite / Box
City
State
Zip code
Phone # (
)
Language: m English m Spanish
Email address
Medical
Group #:
Benefit #:
Class/Div:
AZ-72000-MD
3/2008
Coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
Plan name
m Family
m NO COVERAGE (complete waiver)
1. Prior medical coverage during the past 18 months (individual or other group coverage)?
m N m Y
Prior coverage type:
Prior medical insurance carrier name Policy #
Effective date _ _ / _ _ / _ _ _ _
m Employee only
m Employee and spouse
Term date _ _ / _ _ / _ _ _ _
m Employee and child(ren) m Family
2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)?
m N m Y
Other coverage type:
Other Medical Insurance carrier name Policy #
Effective date _ _ / _ _ / _ _ _ _
m Employee only
m Employee and spouse
Term date _ _ / _ _ / _ _ _ _
m Employee and child(ren) m Family
3. Medicare coverage:
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
Employee coverage: m N m Y
Medicare ID
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
Spouse coverage:
m N m Y
Medicare ID
Health Savings Account
Group #:
Benefit #:
Class/Div:
AZ-72000-HA 3/2008
If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details.
Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can find additional information on
HSAs on . Select the Quick Link for Spending Account information on the Member page.
Do you elect the Health Savings Account?
Beneficiary for this account will be the employee’s estate. You may change beneficiary information
m N m Y (If no, complete waiver.)
on file with the bank that administers the HSA once the account is established.
(NF) AZ-72000 3/2008
1
Reorder# AZ-51340-SB 8/2008
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