Aetna Voluntary Plans
Enrollment/Change Request
Instructions: Read and fill out the Enrollment/Change Request (all pages). Make a copy for yourself. Give the original to your employer
INFORMATION ABOUT YOU Complete all information
Print your name (first, middle initial, last) Social Security Number Date of birth (MM/DD/YYYY)
Primary language spoken (Idioma principal)
ACTION YOU WANT TO TAKE Check the box next to the action you want to take
I am not currently enrolled and I want to…
I am currently enrolled and I want to…
Enroll in the coverage choices selected below.
Decline this opportunity to participate.
Make changes to my current coverage choices (add, increase, drop, decrease) as selected below.
All of my other coverage choices will remain the same as previously elected.
(If outside of an open enrollment, see “Making Changes Outside of an Open Enrollment.”)
Update my personal and/or my dependent and/or beneficiary information.
Drop all of my current coverage choices
Your payroll deductions will be taken after taxes are taken.
YOUR COVERAGE CHOICES Check() the box for the level of coverage you want. Coverage
Please name the beneficiary of your accidental death benefit.
Non-Tobacco with Health Screening
Tobacco with Health Screening
EMPLOYER GROUP INFORMATION
This section is to be completed by your employer.
Employee ID Hire date (MM/DD/YYYY) Pay type Total deduction ($) Effective date (MM/DD/YYYY)
Location or site code Authorized signature Title
INFORMATION ABOUT YOU Repeat your name and Social Security number here.
Print your name (first, middle initial, last)
INFORMATION ABOUT YOUR DEPENDENTS List the dependents for which you are adding/changing/removing coverage.
Please print clearly in blue or black ink.
If you have more dependents, write down their information on a separate sheet and attach it to this Enrollment/Change Request
Add
Change Remove Print dependent’s name (first, middle initial, last)
of birth
Relationship: Spouse/Civil Union Partner/Domestic Partner
Child
Address (if different than yours)
Add Change
Remove
Other (Specify):
Print dependent’s name (first, middle initial, last) Social Security Number
Sex
Male / Female
Relationship:
Date of birth Enrolled in:
Spouse/Civil Union Partner/Domestic Partner
Child
(if different than yours)
Add
Change Remove
Other (Specify):
Print dependent’s name (first, middle initial, last) Social Security Number
Sex
Male / Female
Relationship:
Date of birth Enrolled in:
Spouse/Civil Union Partner/Domestic Partner
Child
Address (if different than yours)
Other (Specify):
MAKING CHANGES OUTSIDE OF AN OPEN ENROLLMENT
Please read below to see if you are able to make changes to your coverage. You can add to or increase your coverage during the plan year only if permitted by your employer when you have a Qualifying Life Event (QLE). If your deductions are taken after taxes, you may drop or decrease coverage at any time. QLEs fall under one of these two categories:
• Loss of Other Coverage (LOC): If you previously declined coverage because you or your dependents were already covered under another health plan and you or your dependents have lost that other coverage, you may be able to enroll yourself and your dependents. If you had a recent LOC, go to the list on the right and check the box next to your LOC and supply the date of the LOC.
• Family Status Change (FSC): Whether you are currently enrolled or previously declined coverage, you may be able to add or increase, coverage when you experience certain FSC events. If you had a recent FSC, go to the list on the right and check the box next to your FSC and supply the date of the FSC.
Next, complete the rest of this Enrollment/Change Request. When finished, make a copy and submit it to your employer with your documentation attached. You must submit this Enrollment/Change Request, together with documentation, to your employer within 31 days of the LOC/FSC.
Loss of Other Coverage (LOC):
Divorce, legal separation or death
Termination of employment of a dependent
Reduction of a dependent’s hours
Termination of your or your dependents’ COBRA rights
Loss of employer’s contribution to spouse’s, civil union partner’s or domestic partner's coverage
Dependent child losing eligibility as a dependent
Other loss of coverage
Family Status Change (FSC):
Divorce, legal separation or death
Marriage, established a civil union or domestic partnership
Birth or adoption of a dependent
Other
Date of LOC or FSC (mm/dd/yyyy)
YOUR AUTHORIZATION You, the employee, must sign and date this Enrollment/Change Request for all new enrollments or coverage changes. By signing and submitting this Enrollment/Change Request:
1 I acknowledge that: The Accident Plan, Critical Illness Plan and Hospital Indemnity Plan are not comprehensive, major medical insurance but are fixed indemnity plans that pay fixed daily dollar benefits for covered services without regard to the health care provider's actual charges. The benefit payments are not intended to cover the full cost of medical care. I am responsible for the provider's charges. THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL
COVERAGE
UNDER THE AFFORDABLE CARE ACT. THESE ARE SUPPLEMENT TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.
2. I represent that all information supplied in this Enrollment/Change Request is true and complete to the best of my knowledge and/or belief. I have read and agree to the Conditions of Enrollment on the last page of this Enrollment/Change Request.
Employee signature
Today’s date (MM/DD/YYYY)
CONDITIONS OF ENROLLMENT Applicant acknowledgments and agreements
On behalf of myself and the dependents listed on this Enrollment/Change Request, I agree to or with the following:
1. I acknowledge that by enrolling, all coverage is underwritten by Aetna Life Insurance Company (Aetna) 151 Farmington Avenue, Hartford, CT 06156.
2. I authorize deductions from my earnings for any premium payments or premium contributions required for coverage or I agree to make any necessary premium payments directly to Aetna as required for coverage, whichever applies.
3. I understand and agree that this Enrollment/Change Request may be transmitted to Aetna or its agent by my employer or its agent. I authorize any physician, other healthcare professional, hospital or any other healthcare organization ("Providers") to give Aetna or its agent information concerning the medical history, services or treatment provided to anyone listed on this Enrollment/Change Request, including those involving mental health, substance abuse and HIV/AIDS. I further authorize Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my spouse/civil union partner/domestic partner and competent adult dependents and I have obtained their consent to those terms. I understand that this authorization is provided under state law and that it is not an "authorization" within the meaning of the federal Health Insurance Portability and Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original.
4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or other description of the plan.
5. I understand that all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC and Aetna Specialty Pharmacy, LLC, wholly owned subsidiaries of Aetna Inc., are participating providers and independent contractors of Aetna, and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the changes shall be provided in accordance with applicable state law. Aetna does not provide health or dental care services and, therefore, cannot guarantee any results or outcome. Some benefits are subject to limitations or maximums.
6. Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Arkansas Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: The falsity of any statement in this Enrollment/Change Request shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by Aetna. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties. Attention Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention Oregon Residents: Any person who with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Penalties may include imprisonment, fines and denial of insurance benefits.
This Enrollment/Change Request is not proof of coverage.
