Form CEF-2005TX "Enrollment/Change Form - the Guardian Life Insurance Company of America" - Washington

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Download Form CEF-2005TX "Enrollment/Change Form - the Guardian Life Insurance Company of America" - Washington

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Enrollment / Change Form
The Guardian Life Insurance Company of America
Planholder Name (Company Name)
Guardian Group Plan No.:
Planholder Street Address
City
State
Zip
:
EMPLOYER USE ONLY
New Application
Add Dependent(s)
Remove Dependent(s)
Change Address
Change Name
Drop Coverage as of:
/
/
Class
Hours Worked
Division
Benefit Effective
Western Regional Office, P.O. Box 2454, Spokane, WA 99210-2454
Keep a copy for your records and return to:
-
ABOUT YOURSELF
Please print clearly and in black or blue ink
First, Middle Initial, Last Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Sex
:
M
F
Address
City
State
Zip
Business Phone#
Home Phone #
Preferred Email
The best way to reach you:
Day Phone
Evening Phone
Email
Job Title:
Work Status/Eligibility:
Date work status began:
Annual Salary/Earnings:
Full Time
Part Time
Retired
Cobra/State Continuation
$
?
ARE YOU MARRIED
Yes
No
?
DO YOU HAVE CHILDREN OR OTHER DEPENDENTS
Yes
No
ABOUT YOUR DEPENDENTS
Add
Spouse First, Middle Initial, Last Name
Sex
Date of Birth (mm/dd/yyyy)
Social Security Number
Marriage Date
Change
Drop
M
F
Add
Sex
Child (1):
Date of Birth (mm/dd/yyyy)
Attending Since
Full-time student, at
City/State
Change
(school):
M
F
Drop
Add
Sex
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Child (2):
Full-time student, at
Change
(school):
M
F
Drop
Add
Sex
Child (3):
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Full-time student, at
Change
(school):
M
F
Drop
Add
Sex
Child (4):
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Full-time student, at
Change
(school):
M
F
Drop
To drop coverage for yourself or your dependents, check the box(es) to the left of the name(s) and select the coverage(s) to drop below. Attach a separate sheet if you
wish to drop more than one dependent from different coverage’s.
Dental
CHOOSE YOUR DENTAL COVERAGE: Check one box only
Find dental providers online at
www.guardianlife.com
or check the directory of providers.
Employee Alone
I Waive This Coverage
Employee & Spouse
I Waive This Coverage
Employee & Child(ren)
I Waive This Coverage
Entire Family
I Waive This Coverage
If waiving coverage, are you covered under another dental plan?
Yes
No
If waiving dependent coverage, are your dependents covered under another dental plan?
Yes
No
If you or your family has lost dental coverage, please explain below. Late entrant penalties may apply.
Reason for Loss of coverage:
Date of coverage loss:
Termination of Employment.
Divorce.
Death of Spouse.
Termination or Expiration of coverage
CEF-2005TX
Enrollment / Change Form
The Guardian Life Insurance Company of America
Planholder Name (Company Name)
Guardian Group Plan No.:
Planholder Street Address
City
State
Zip
:
EMPLOYER USE ONLY
New Application
Add Dependent(s)
Remove Dependent(s)
Change Address
Change Name
Drop Coverage as of:
/
/
Class
Hours Worked
Division
Benefit Effective
Western Regional Office, P.O. Box 2454, Spokane, WA 99210-2454
Keep a copy for your records and return to:
-
ABOUT YOURSELF
Please print clearly and in black or blue ink
First, Middle Initial, Last Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Sex
:
M
F
Address
City
State
Zip
Business Phone#
Home Phone #
Preferred Email
The best way to reach you:
Day Phone
Evening Phone
Email
Job Title:
Work Status/Eligibility:
Date work status began:
Annual Salary/Earnings:
Full Time
Part Time
Retired
Cobra/State Continuation
$
?
ARE YOU MARRIED
Yes
No
?
DO YOU HAVE CHILDREN OR OTHER DEPENDENTS
Yes
No
ABOUT YOUR DEPENDENTS
Add
Spouse First, Middle Initial, Last Name
Sex
Date of Birth (mm/dd/yyyy)
Social Security Number
Marriage Date
Change
Drop
M
F
Add
Sex
Child (1):
Date of Birth (mm/dd/yyyy)
Attending Since
Full-time student, at
City/State
Change
(school):
M
F
Drop
Add
Sex
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Child (2):
Full-time student, at
Change
(school):
M
F
Drop
Add
Sex
Child (3):
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Full-time student, at
Change
(school):
M
F
Drop
Add
Sex
Child (4):
Date of Birth (mm/dd/yyyy)
City/State
Attending Since
Full-time student, at
Change
(school):
M
F
Drop
To drop coverage for yourself or your dependents, check the box(es) to the left of the name(s) and select the coverage(s) to drop below. Attach a separate sheet if you
wish to drop more than one dependent from different coverage’s.
Dental
CHOOSE YOUR DENTAL COVERAGE: Check one box only
Find dental providers online at
www.guardianlife.com
or check the directory of providers.
Employee Alone
I Waive This Coverage
Employee & Spouse
I Waive This Coverage
Employee & Child(ren)
I Waive This Coverage
Entire Family
I Waive This Coverage
If waiving coverage, are you covered under another dental plan?
Yes
No
If waiving dependent coverage, are your dependents covered under another dental plan?
Yes
No
If you or your family has lost dental coverage, please explain below. Late entrant penalties may apply.
Reason for Loss of coverage:
Date of coverage loss:
Termination of Employment.
Divorce.
Death of Spouse.
Termination or Expiration of coverage
CEF-2005TX
IMPORTANT NOTES:
Proof of insurability does not apply to dental, but if you waive dental coverage and later decide to enroll, you may be subject to a late entrant penalty and your
dental benefits may be limited for a period of time. Guardian may waive late-entrant penalties if you lose dental coverage due to termination of the plan, loss of
employment, death of spouse, divorce or where a court has ordered coverage be provided for an eligible spouse or eligible children, provided you apply within
31 days.
SIGNATURE
• I hereby apply for the group benefit(s) that I have chosen above.
• I understand that I must meet eligibility requirements for all coverage’s that I have chosen above.
• I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chosen above.
• I attest that the information provided above is true and correct to the best of my knowledge.
• Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may be guilty of insurance fraud.
SIGNATURE OF EMPLOYEE
DATE
PLEASE RETAIN A PHOTOCOPY FOR YOUR RECORDS AND SUBMIT THIS FORM TO GUARDIAN
CEF-2005TX
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