Hint Group Enrollment - Group Enrollment/change Request Form
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7GROUP ENROLLMENT/CHANGE REQUEST
Group Information – to be completed by [Employer]:
[Carrier Logo]
[Carrier Name]
Group Name:
[Group Number]:
[Class Code]:
A. Type of Activity – to be completed by [Employer]. Refer to instructions [on back] before completing this form. Print clearly.
Activity – Check all that apply
Effective Date/
Date of Hire/Reason for Change
Date of Event
Enrollment of a new [Enrollee/Subscriber]
_____/_____/_____
Date of Hire: _____/_____/_____
Add Spouse[/Civil Union Partner]
_____/_____/_____
________________________________________________________
[
Civil Union Partner]
[_____/_____/_____]
[_______________________________________________________]
Add Domestic Partner
_____/_____/_____
________________________________________________________
Add Dependent Child
_____/_____/_____
________________________________________________________
Add Over-Age Child as a Dependent Under 30(and complete
_____/_____/_____
________________________________________________________
section A 4)
[Employee] Withdrawal/Termination
_____/_____/_____
________________________________________________________
Remove Spouse[/Civil Union Partner]
_____/_____/_____
________________________________________________________
[
Civil Union Partner]
[_____/_____/_____]
[_______________________________________________________]
Remove Domestic Partner
_____/_____/_____
________________________________________________________
Remove Dependent Child
_____/_____/_____
________________________________________________________
Remove Over-Age Child as a Dependent Under 30
_____/_____/_____
________________________________________________________
Name Change
_____/_____/_____
________________________________________________________
Change Plan
_____/_____/_____
________________________________________________________
Other
_____/_____/_____
________________________________________________________
[Add/Change Office ID Numbers: Primary/OB/Gyn/ Dentist]
_____/_____/_____
________________________________________________________
For Employee
For Spouse/Civil Union Partner*
For Dependent or Over-age Child
Total Disability*
Length of Continuation (in months):
COBRA/NJSGC
COBRA/NJSGC
18
36
Length of Continuation (in months):
Length of Continuation (in months):
Date of Loss of Coverage: ___/___/___
18
36
18
29
Qualifying Event #:_________________**
Loss of Coverage: ___/___/___
Date of Loss of Coverage: ___/___/___
Date of Qualifying Event: ___/___/___
Qualifying Event #:__________________**
Qualifying Event #:____________**
[Billing:
Group
Home (what address?)
Date: ___/___/___
Date of Qualifying Event: ___/___/___
Section B OR
Dependent Under 30
[Billing:
Group
Home (Section B)]
Section [F]]
Qualifying Event #:__________________**
[Billing:
Group***
Home (what address?)
*Attach proof of disability
*Civil union partners are eligible to make an
Section B OR
election pursuant to NJSGC, if applicable..
Section [G]]
**Qualifying event #s: see list in Instructions. [ ***Billing through the group for a Dependent Under 30 Continuation Election requires agreement by the employer at
Section [L] .]
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