Multi-Life, Inc.

  Marketers of: Group - Life - Health - Disability

A Brokerage Firm Serving the Insurance Needs of Agents and Companies Throughout the Southeast  

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EMPLOYER GROUP INSURANCE ENROLLMENT FORM

Open Enrollment Ends at Midnight on December 31, 2005

American Health Centers 7185
   
Facility Name
Select PPO
TN PHCS TN HealthCare Middle TN Signature Health
Facility Location
AL
KY
MS
   
Employee's Name:
(Last, First, Middle)
Address:
City:
State: Zip:
Social Security # :
BirthDate:
DD/MM/YYYY
Employment Date
Hourly Salaried
Eligibility Status
Active
COBRA
Sex
Male
 Female
Are you currently Married?
Yes, Married or Separated.
No, Single, Widowed, or Divorced.

 

MEDICAL BENEFITS
Select Coverage
Emp Only
Emp + Spouse
Emp+Child(ren)
Emp+Spouse+Child(ren)
Effective Date:
MM/DD/YYYY

 

DENTAL BENEFITS
Select Coverage
Emp Only
Emp + Spouse
Emp+Child(ren)
Emp+Spouse+Child(ren)
Effective Date:
MM/DD/YYYY

 

DEPENDENT COVERAGE: LIST ALL ELIGIBLE DEPENDENTS YOU WISH COVERED UNDER THE MEDICAL AND/OR DENTAL PLAN

 
 

Dependent Name:
Last, First, Middle

Birth Date
SSN

Sex

(M or F)

Mo.
Day
Year
Spouse
Dependent Child #1
Dependent Child #2
Dependent Child #3
Dependent Child #4

Please indicate any dependent children listed above who are 19 or older and are full time students:

DEPENDENTS NAME
NAME OF SCHOOL

Are you or your eligible dependents covered by any other health coverage? Yes No

Pre-Existing Conditions Limitations: This plan contains a 12 month pre-existing conditions limitations for timely and special enrollment and an 18 month pre-existing conditions limitations for late enrollees. Prior period of "creditable coverage" under another health plan may shorten or eliminate this pre-existing condition period unless you had a 63 day lapse in coverage after your former coverage terminated. A waiting period with this plan generally does not count as a lapse in coverage. You must submit a Certificate of Creditable Coverage obtained from your previous carrier as evidence of this creditable coverage.

 

FOR LIFE INSURANCE ONLY
Beneficiary/Primary Relationship
Beneficiary/Contingent Relationship

 

I certify that I am an eligible employee working at least the minimum hours per week required by my employer's plan, and I authorize my employer to deduct from my earnings the required premium contribution, if any, toward the cost of the coverage.

Please Check Box for Electronic Signature Date:

 

WAIVER OF GROUP MEDICAL AND/OR DENTAL COVERAGE
(must have a reason)
I hereby waive medical coverage for:

myself
dependents
Reason for declining:
I hereby waive dental coverage for:

myself
dependents
Reason for declining:

 

I have been given an opportunity to apply for group coverage as offered by my employer, and after careful consideration, I have decided NOT to take advantage of this offer as indicated by this waiver. I understand that in the event that I should decide to apply for such coverage hereafter that such subsequent application shall be subject to the applicable terms and conditions of the plan document which may require additional limitations and waiting periods.

Please Check Box for Electronic Signature Date:

 

A copy of the data above will be printed when you submit this form.

Please retain for your records.