Form GN-80124-CG "Employee Change Form - Humana"

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Humana Employee Change Form
Please print clearly and fill in each applicable circle.
Current Medical Group number
Benefit number
Class/Division
Current Dental Group number
Proposed Effective Date for change: __ __ / __ __ / __ __ __ __
Company name
Company city
State
Employee Information and Changes
Please provide employee information and indicate all applicable employee changes.
Last name
First name
MI
Social Security number
m Change Medical benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change or Select Employee Primary Care Physician (HMO and POS only):
Primary care physician: ______________________________________________ Physician ID: ________________________
m Change Dental benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Change or Select Employee Primary Care Dentist (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: ___________________________________________________ Facility number: ______________________
m Change Basic Life benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change Basic Life Beneficiary: Group number: ________________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Voluntary Life Beneficiary: Group number: ____________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Vision benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Cancel My Coverage for the following products: m Medical m Dental m Basic Life m Voluntary Life m Short-term Income Protection
m Vision m Health Savings Account (HSA) m Health Care FSA m Dependent Care FSA
Qualifying Event Information
Please indicate the qualifying event date and reason for employee or dependent changes below.
Qualifying event date: __ __ / __ __ / __ __ __ __
Reason for change:
m Re-hire
m Marriage
m Spouse terminates employment
m Employer contribution ceases
m Legal separation
m Spouse’s employer terminates coverage
m Dependent birth / adoption
m Divorce
m Spouse changes from full-time to
part-time employment
m Dependent change to full-time student
m Spouse deceased
m Other: __________________________
Change Address Information
Address change applies to:
m Employee only m Employee and all covered dependents
m Only for the following dependent (please print full name): Last name
First name
MI
New street address
Apt / Suite / PO Box number
City
State
Zip code
County
Email address
Phone number
GN-80124-CG 11/2006
1
Reorder# GN-99955-CG 3/2009
Print Form
Humana Employee Change Form
Please print clearly and fill in each applicable circle.
Current Medical Group number
Benefit number
Class/Division
Current Dental Group number
Proposed Effective Date for change: __ __ / __ __ / __ __ __ __
Company name
Company city
State
Employee Information and Changes
Please provide employee information and indicate all applicable employee changes.
Last name
First name
MI
Social Security number
m Change Medical benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change or Select Employee Primary Care Physician (HMO and POS only):
Primary care physician: ______________________________________________ Physician ID: ________________________
m Change Dental benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Change or Select Employee Primary Care Dentist (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: ___________________________________________________ Facility number: ______________________
m Change Basic Life benefit/class to: Benefit number: ____________________________ Class/Division: _______________________
m Change Basic Life Beneficiary: Group number: ________________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Voluntary Life Beneficiary: Group number: ____________________________
Primary beneficiary name:
Last name
First name
MI
Secondary beneficiary name: Last name
First name
MI
m Change Vision benefit/class to: Benefit number: ____________________________
Class/Division: _______________________
m Cancel My Coverage for the following products: m Medical m Dental m Basic Life m Voluntary Life m Short-term Income Protection
m Vision m Health Savings Account (HSA) m Health Care FSA m Dependent Care FSA
Qualifying Event Information
Please indicate the qualifying event date and reason for employee or dependent changes below.
Qualifying event date: __ __ / __ __ / __ __ __ __
Reason for change:
m Re-hire
m Marriage
m Spouse terminates employment
m Employer contribution ceases
m Legal separation
m Spouse’s employer terminates coverage
m Dependent birth / adoption
m Divorce
m Spouse changes from full-time to
part-time employment
m Dependent change to full-time student
m Spouse deceased
m Other: __________________________
Change Address Information
Address change applies to:
m Employee only m Employee and all covered dependents
m Only for the following dependent (please print full name): Last name
First name
MI
New street address
Apt / Suite / PO Box number
City
State
Zip code
County
Email address
Phone number
GN-80124-CG 11/2006
1
Reorder# GN-99955-CG 3/2009
Group Number
Social Security Number
Dependent Changes
Please complete this section for all dependent changes.
1
Last name
First name
MI
Date of birth _ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
2
Last name
First name
MI
Date of birth _ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
3
Last name
First name
MI
Date of birth _ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
4
Last name
First name
MI
Date of birth _ _ / _ _ / _ _ _ _
Social Security number
Gender: m Female m Male
Relationship: m Spouse m Child m Other:
Dependent status (if applicable): m Full-time student m Disabled
If disabled, indicate reason:
m Add or m Delete dependent to/from my current plan for the following products: m Medical
m Dental
m Basic Life
m Voluntary Life
m Vision
m Change or Select Primary Care Physician (HMO and POS only):
Primary care physician: __________________________________________________ Physician ID: ________________________
m Change or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):
Primary dentist: _______________________________________________________ Facility number: ______________________
Signature -
please sign below if requesting changes
Employee or legal representative signature: ______________________________________________
Date: ______________________
Name and relationship of legal representative: _________________________________________________________________________
GN-80124-CG 11/2006
2
Reorder# GN-99955-CG 3/2009
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