EMPLOYEE MEMBER ENROLLMENT FORM
New Enrollment Late Applicant Special Enrollment Change In Current Status
Add New Dependent Change Of Address Change Of Coverage Termination
PLAN SPONSOR: GROUP #: IC #:
First Name: M.I.: Last Name
Address:
City: State: Zip Code:
Home Ph: Work Ph: Other Ph:
Gender: Male      Female SSN: Birthdate:
Marital Status: Single      Married      Divorced      Widowed     
COVERAGES (Please select from the menus below)
PLAN MEDICAL DENTAL VISION LIFE AD D

DEPENDENT INFORMATION (If dependent is disabled or a full-time student, verification may be required)
1 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
2 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
3 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
4 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
5 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
6 Type Gender First Name M.I. Last Name Birthdate SSN
M   F
Disabled and/or Handicapped Full-time Student Term. Date:
PRIMARY/SECONDARY BENEFICIARY DESIGNATION
  Name Address Relationship SSN Birthdate Pct/Type
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:  Group Number: 
Name of other group/entity 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) indicated above.

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.


PLEASE READ AND AGREE TO THE FOLLOWING (Mark Checkboxes)
  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 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.


I agree that if contributions are required for any of the above coverages, I authorize the Company to deduct from my Commission Settlement 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/COMMENTS: