Group Enrollment Form
 New Enrollment  Late Applicant  Special Enrollment  Change In Current Status
 Add New Dependent  Change Address  Change Coverage  Termination
  Do you have a Certificate of Coverage?    Yes  No    If 'Yes' provide administrator with a copy.
 EMPLOYER: 
 
Date Employed
Coverage Effective Date
PPO
Annual Earnings
 NAME
 
First
 		Mi.
 		Last
 ADDRESS
 CITY
State  Zip 
 Home Phone
Work Phone  Other Phone 
  Gender 
 Male    Female Date of Birth   Social Security  

   MARITAL STATUS    Single  Married  Divorced  Widowed
   COVERAGES (check only those that apply)
 PLAN   MEDICAL   DENTAL   VISION   LIFE   AD D 
 GOLD: 
 SILVER: 
 BRONZE: 
 Decline PLAN: 
  FAMILY: 
 EMPLOYEE: 
 EE PLUS SPOUSE: 
 EE PLUS CHILDREN: 
 EE PLUS CHILD: 
 Decline MEDICAL  		 FAMILY: 
 EMPLOYEE: 
 EE PLUS SPOUSE: 
 EE PLUS CHILDREN: 
 EE PLUS CHILD: 
 Decline DENTAL  		 FAMILY: 
 EMPLOYEE: 
 EE PLUS SPOUSE: 
 EE PLUS CHILDREN: 
 EE PLUS CHILD: 
 Decline VISION 
 EMPLOYEE: 



 Decline LIFE 
 EMPLOYEE: 



 Decline AD D 

   DEPENDENT INFORMATION  - If dependent is disabled or a full-time student, verification may be required.
Dependent Type Gender
 M    F		 Firstname  Mi.  Lastname Date of Birth Soc. Sec. Disabled or
Handicapped?		 Full-time
Student?		 Term
Date
1)  
 Yes  Yes
2)  
 Yes  Yes
3)  
 Yes  Yes
4)  
 Yes  Yes
5)  
 Yes  Yes
6)  
 Yes  Yes
   BENEFICIARY DESIGNATION  Enter "none" if you are declining Life Insurance choices or none are offered.
 
   Name Address Relationship SSN Birthdate Pct/Type
 1. 
   OTHER INSURANCE COVERAGE
Are you or any dependents covered by another group medical, dental, or vision plan?.   Yes    No
If YES, type(s) of coverage:    Medical     Dental     Vision
Name of individual with other coverage:  
Name of insurance carrier or TPA:     Group Number: 
Address:    Phone:  
Name of other employer providing coverage:  
Is Medicare / Medicaid applicable?    Yes    No
 
   BENEFIT WAIVER STATEMENT If you have DECLINED any coverages or benefits please fill in the following
I CERTIFY THAT I have been given an opportunity to apply for the group benefit plan offered by the company and after careful consideration have decided to decline to enroll in the coverage(s) hereon, above indicated.

 
Are you declining due to coverage in another plan?  Yes    No
 
If YES, is this other coverage COBRA?  Yes    No
 
 Other (Please explain)  
 
Important Notice: If you refuse coverage for yourself, you automatically refuse coverage for any dependents. If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. Also, you must indicate the reason for declining enrollment to later be eligible under the special enrollment rules. In addition, if you have a new dependent as the result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

The pre-existing condition limitation is stated in the summary plan description. You and/or your dependents have the right to demonstrate creditable coverage by requesting a certificate of coverage from you prior plan or insurer. If necessary and requested, your employer will assist you in obtaining this certificate.
 
 
I authorize any physician, medical practitioner, hospital, clinic, insurance or reinsurance company, or any other person that has knowledge of me or my dependents health, to give my employer, plan administrator, or their legal representatives any and all such information. I understand that such information may be used to determine eligibility for coverage or benefits and that such information may be released to persons or organizations performing business or services in connection with the processing of any claims submitted under this plan.

BY SUBMITTING THIS FORM I agree that If contributions are required for any of the above coverages, I authorize the Company to deduct from my earnings the applicable contribution(s). for the coverage(s) selected above.

I further certify that I have received and read a summary of the plan description, and any amendments regarding the impact of HIPAA. I certify that the above entered information is true and accurate.
 
NOTES: