Fillable Form (Nf) Az-72000 - Humana Employee Enrollment Form

Last name:

First name:

Dental

Group #:

Benefit #:

Class/Div:

AZ-72000-HD

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)

Prior dental coverage during the past 12 months (individual or other group coverage)?

m N m Y

Prior dental insurance carrier name

Prior coverage type:

Effective date

Policy #

m Employee only

_ _ / _ _ / _ _ _ _

m Employee and spouse

Prior orthodontia coverage in the past 12

Term date

Prior carrier phone # (

)

m Employee and child(ren)

months? m N m Y

_ _ / _ _ / _ _ _ _

m Family

Basic Life

Group #:

Benefit #:

Class/Div:

AZ-72000-BL

3/2008

Primary beneficiary name (Last, First MI)

Secondary beneficiary name (Last, First MI)

Class (employer will provide you

Annual salary (if applicable)

Basic dependent life? m N m Y

with this information if needed)

If no, complete waiver section.

Voluntary Life

Group #:

Benefit #:

Class/Div:

AZ-72000-VL

3/2008

Voluntary employee life

Amount (min $15,000)

Primary beneficiary name (Last, First MI)

Secondary beneficiary name (Last, First MI)

coverage? m N m Y

Voluntary spouse life

Voluntary child(ren) life coverage?

Amount (min. $5,000)

Annual employee salary (if applicable)

coverage? m N m Y

m N m Y

Vision

Group #:

Benefit #:

Class/Div:

AZ-72000-VS

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)

Waiver (refusal of coverage)

AZ-72000-WV

3/2008

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I proclaim that I

was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage. If I have waived any coverage offered to me or my

dependents, my signature is evidence of this action.

I hereby waive coverage for (check all that apply):

I decline to apply for group coverage because of:

Medical for: m Myself m My spouse m My dependent child(ren)

m Spousal coverage

Dental for:

m Myself m My spouse m My dependent child(ren)

m Medicare supplement

Basic Life for: m Myself m My spouse m My dependent child(ren)

m Individual coverage

Vision for:

m Myself m My spouse m My dependent child(ren)

m Coverage under another carrier’s plan provided by my employer

Health Savings Account for: m Myself

m Other:

Agreement

AZ-72000-AA

3/2008

True and complete acknowledgement

I understand, agree and represent:

•

I have read this document or it has been read to me and answers provided are true and complete to the best of my knowledge and belief.

•

Neither my employer nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other rights

and requirements.

•

If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the certificate of coverage/certificate of insurance.

If I have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment within 31

days after the qualifying event.

•

In the event that I should decide to apply for coverage hereafter, that subsequent application shall be subject to the applicable terms and conditions of the

master group contract(s) or plan provisions which may require additional limitations and waiting periods.

•

I may be required to furnish, at my own expense, evidence of health status satisfactory to Humana.

•

If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my

dependents provided that I request enrollment within 31 days after my other coverage ends.

•

Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future application for coverage.

•

If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize

Humana or its banking partners to provide my account number to my employer for the purposes of depositing any contributions.

•

Any misrepresentation contained herein relied on by Humana may be used to reduce or deny a claims or void the contract within the contestable period if such

misrepresentation materially affected the acceptance of the risk.

Authorization

I authorize any third party to have information regarding myself. This includes any medical or non-medical information and to share any and all such information

with Humana, its reinsurer or its legal representatives, and its affiliates.

(NF) AZ-72000 3/2008

Reorder# AZ-51340-SB 8/2008