Note for California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.
For group policies issued, amended, delivered, or renewed in California, dependent coverage includes individuals who are registered domestic partners and their dependents.
No Cost Language Services. You can get an interpreter and have documents read to you in your language. For help, call us at the number listed on your ID card or 877-233-3797. For more help call the CA Dept. of Insurance at 800-927-4357.
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al número que gura en su tarjeta de identi cación o al 877-233-2797. Para obtener más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.
Note for 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.
Note for Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer les a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Note for Georgia, Oregon and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a
false or deceptive statement may have violated state law.
Note for Maryland and Washington, D.C. 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 confinnement in prison.
Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Note for New Mexico and 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 civil fines and criminal penalties.
Note for 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.
Note for Texas Residents: 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, may be 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.
Note for Washington Residents: For groups policies issued, amended, delivered, or renewed in Washington, dependent coverage includes individuals who are registered domestic partners and their dependents.
Tips for filling out this form
Missing, incomplete or illegible information can cause delays in
adding new employees to the system and could create errors in
billing. To ensure proper handling of your enrollment forms, please
make sure the following areas are completed:
Policy Name and Group Number – to make sure plan members are
added to the correct group.
Department/Division Numbers – so plan members are added in
the proper locations, and appear in the appropriate section on the
billing if the group has multiple departments or divisions.
Social Security Numbers – the most important identi er for plan
members when calling in with claims or administrative questions.
Please double check to make sure your social security number is
accurate and written clearly.
Full-time Employment Date – needed so the correct e ective date
is calculated for new members.
Class Number – needed when the plan has more than one class of
Changing Dependent Codes – When adding or dropping dependents,
please note whether this change is because of a “life event” or
for some other reason. (Examples of life events: marriage, birth of a
child, divorce . . . ) Please remember to include the date of the event.
Late entrant status will be applied if a life event is not included. Be
specific when changing status so all dependents who are still eligible
will be covered.
In order to provide better service, our administration system
utilizes image technology. In the image environment, we scan your
enrollment forms into our system, making them easier and faster to
access. Better quality forms help us to process your enrollments faster.
Unfortunately, certain forms are dificult or impossible to scan. The
following list of helpful hints will make your forms easier to scan:
1) submit clear, legible enrollment forms.
2) underline or circle important information.
3) use blue or black ink.
1) submit dark copies as they appear black on imaging.
2) highlight, which blackens the area so it cannot be read.
3) write on the top or bottom margins. This information is not
always captured on the image system.