today’s date. If the employee is waiving coverage, do not submit the application but retain it for your records.
Company Name Department # Plan Variation Reporting Code Benefit Level/Class Code, if applicable Medical ______ Vision ______ Medical ______ Vision ______ Life/AD&D ______ Suppl. Life ______ Life Spouse Life ______ Suppl. AD&D Cancellations: Last Date of Employment ___ /___ /___ New Enrollment/Additions: (Check one) Requested Effective Date of Cancellation ___ /___ /___ Date of Hire ___ /___ /___ Requested Date of Coverage ___ /___ /___ Cancel all coverage Status Change (PT to FT) Cancel all listed below – Section B Return from Leave/Layoff Reason: (check one) Employee Terminated Court ordered dependent Moved out of service area Other (describe) ________________________ Dependent reached dependent max age COBRA/State Continuation start date _______ stop date________ Other (describe)____________________________ Annual Open Enrollment Requested Effective Date of Enrollment ___ /__ /___ Employee Type Retire Date ______ COBRA/State Cont. Signature ________________________________________________ Date ___________________ Employer Position_____________________________ Phone Number________________________ A. Employee Information First Name Social Security Number Home Phone Work Phone Email Address Date of Birth Physician* (First & Last Name) / Physician’s ID Number Primary Care Dentist Number* Race – Check all that apply (Optional)** Marital Status American Indian/Alaska Native Black/African-American Hispanic/Latino Native Hawaiian/Pacific Islander Other–Please specify ___________________________*IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care Dentist
(PCD) selection.**Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being and
not for eligibility or claim payment determination. Coverage Provided by “UnitedHealthcare and Affiliates”:Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of Ohio or UnitedHealthcare of
Dental coverage provided by UnitedHealthcare Insurance CompanyLife Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company