YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Group Enrollment / Change or Waiver Form 301083 COBRA - If the individual is a continuee: Qualifying Event_______________ Date of Event ___________________ POLICY AND DIV. # 010- CERT.# NAME AND ADDRESS OF EMPLOYER (Policyholder) CITY OF LINCOLN MAILING ADDRESS: P.O. BOX 81889, LINCOLN, NE 68501-1889 800-659-2223 / FAX: 402-466-0003 1. TO ENROLL DENTAL TO TERMINATE ALL COVERAGES EMPLOYEE INFORMATION: MARITAL STATUS SINGLE MARRIED SOCIAL SECURITY NUMBER EMPLOYEE’S LAST NAME, FIRST, MI DEPT.# DATE OF BIRTH MALE FEMALE FULL TIME DATE OF HIRE OCCUPATION REHIRE - REHIRE DATE HOURS WORKED EACH WEEK ARE YOUR EARNINGS PAID: HOURLY OR SALARIED STREET ADDRESS CITY STATE ZIP ARE YOU COVERED UNDER ANOTHER DENTAL INSURANCE PLAN? EMPLOYEE: YES NO DEPENDENTS: YES NO DEPENDENT COVERAGE INFORMATION. LIST ALL ELIGIBLE DEPENDENTS TO BE ADDED OR DELETED. (Employee must be enrolled to cover dependents) PRINT FULL LEGAL NAME (LAST, FIRST, M) 1 2 3 4 5 6 7 ADD DROP RELATIONSHIP SEX DATE OF BIRTH SOCIAL SECURITY NUMBER PLEASE SIGN (EMPLOYEE / POLICYHOLDER SIGNATURES) As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records. X X Employee Signature (Do Not Print) Date Policyholder Signature Date In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements on back.) EMPLOYEE LATE ENTRANT DATE _______________________ DEPENDENT LATE ENTRANT DATE ______________________ 2. TO CHANGE NAME CHANGE Effective Date Class Dep. Code NEW NAME ADD DEPENDENT COVERAGE IF DUE TO MARRIAGE, WHAT IS THE DATE OF MARRIAGE? OLD NAME IF DUE TO BIRTH/ADOPTION OF A CHILD, WHAT IS THE DATE OF EVENT? IF DUE TO LOSS OF COVERAGE, DATE AND REASON: OTHER, THE DATE OF EVENT AND PLEASE EXPLAIN: DROP DEPENDENT COVERAGE NUMBER OF DEPENDENTS STILL COVERED: DUE TO DIVORCE DUE TO DEATH DUE TO ANNUAL ELECTION PERIOD OTHER: PLEASE EXPLAIN: EFFECTIVE DATE OF DROP: 3. TO WAIVE IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for: myself (does not apply to TRUST policies) spouse only child(ren) only spouse and child(ren) because______________________________________________ Name of Insurance Co. & Employer of Dependent __________________________________ Should I desire to apply for this group insurance in the future, I realize that a “late entrant” penalty may be applied. GR 875 Rev. 8-03 112403L
