HC-ENR68
H
Enrollment / Change Form (Consolidated)
EMPLOYEE’S SIGNATURE / DATE
CT Cat. #740013a Rev. 7-12 (OVER)
Please print and thank you for providing this information
SIGNATURE - The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form which I have read and understand.
Employer: Complete Section A
Employee: Complete Sections B-H
MAILING ADDRESS
*DEPENDENTS - Dependents are covered under the medical plan to age 26. Proof of student status may be required for dental and/or vision coverage. If totally disabled prior to dependent eligibility end date, attach proof of
disability for eligibility review.
(Zip Code)(State)(City)
B
WORK PHONE
EMPLOYER NAME
TYPE OF CHANGE:
OTHER HEALTH CARE COVERAGE:
Do you or your dependents have other health insurance under a group plan, HMO, or Medicare?
If yes, please provide the following:
G
EMPLOYEE DATE OF BIRTH
(MM/DD/CCYY)
EMPLOYEE IDENTIFICATION NUMBERHOME E-MAIL ADDRESSHOME PHONE
( ) ( )
EMPLOYEE NAME
(Last) (First) (M.I.)
NAME OF PERSON COVERED SOCIAL SECURITY NO.
Part A Part B MEDICAID
MEDICARE
OTHER
INSURANCE
CARRIER
SPOUSE’S SIGNATURE / DATE
EMPLOYER’S SIGNATURE / DATE
SOCIAL SECURITY NO.
EMPLOYER ADDRESS
Insured and/or Administered by
Cigna Health and Life Insurance Company
Cigna HealthCare of Connecticut, Inc.
*If you have checked off one of the Flexible Spending Accounts in Section D, please make sure you have completed the corresponding enrollment form included in this package.
Cigna HealthCare of (city/state):
C
If you choose a Managed Care Medical Option other than Open Access Plus, print the name of the Cigna HealthCare
network. (See the cover or first page of the physician directory). Include the name of the city and state.
MANAGED CARE MEDICAL OPTIONS: OTHER MEDICAL OPTIONS:
OPTION # (if applicable):
CIGNA CHOICE FUND OPTIONS:
FLEXIBLE
SPENDING
ACCOUNT
OPTIONS:
D
VISION
OPTIONS:
F
DENTAL OPTIONS:
E
DIVISION/BRANCH/LOCATION/CLASS
NETWORK ID
DATE OF HIRE
(MM/DD/CCYY)
CIGNA CHOICE FUND
ANNUAL AMOUNT
Dependent *
Dependent *
Dependent *
PCP or HCC Choice -
Cancel
Add
Cancel
Add
Cancel
Add
Cancel
Add
Employee
Spouse
Relationship
Relationship
Relationship
PCP or HCC Choice -
PCP or HCC Choice -
PCP or HCC Choice -
PCP or HCC Choice -
Dent.
Med.
Dent.
Cancel
Add
Med.
Vis.
Dent.
Med. Vis.
Dent.
Med.
F
M
F
M
F
M
F
M
F
M
2nd Choice -
1st Choice -
2nd Choice -
1st Choice -
2nd Choice -
1st Choice -
2nd Choice -
1st Choice -
2nd Choice -
1st Choice -
Vis.
Vis.
Dent.
Med. Vis.
MEDICARE ID #
CIGNA ACCOUNT NO. BRANCH CODE CDH GROUP NO. MEDICAL BEN. OPTION
DENTAL BEN. OPTION VISION BEN. OPTION
Add Dependent(s) *
Cancel Employee
Cancel Dependent(s) *
Date:
Last Date of Coverage:
Last Date of Coverage:
Address Change
Transfer to COBRA
18 mos. 29 mos. 36 mos.
Family Security Benefit/Surviving Spouse
Retirement
Other
* List Names in Section B
A
Point-of-Service (or DPP or CHA)
HMO
Point-of-Service Open Access
HMO Open Access
Open Access Plus
Preferred Provider Option (PPO)
Preferred Provider Access (PPA)
Medical Indemnity
____________________________
HRA
HSA
Pharmacy HRA
Dental HRA
with PPO
with Open Access Plus
with Indemnity
Decline Coverage
1 2 3
Health Care*
Dependent
Day Care*
Decline
Coverage
Decline
Coverage
Cigna Care Network
DHMO (Cigna
Dental Care )
Dental PPO
Dental Indemnity
Cigna
Vision
Decline
Coverage
®
®
®
Yes
No
EFFECTIVE DATE
EFFECTIVE DATE OF ADD/CHANGE/
CANCELLATION (MM/DD/CCYY)
OPEN ENROLL.
NEW ENROLL.
CHANGE
REINSTATE
I WOULD LIKE COVERAGE FOR ME
AND MY DEPENDENTS.
(Specify last name if different from yours)
Last Name
First Name
M.I.
DEPENDENT
SOCIAL
SECURITY NO.
DATE OF
BIRTH
MM DD CCYY
GEN-
DER
COVERAGE
SELECTION
FULL TIME
STUDENT? *
Yes No
If you choose a Managed Care Medical Option:
Select your choice of Primary Care Physician
(PCP) or HealthCare Center (HCC) and enter
the ID Numbers below. Note: PCP selection is
optional for Open Access Plans.
EXISTING
PATIENT?
Yes No
If you choose the Cigna
Dental Care Option:
Enter your 1st and 2nd
choice of Dental Office
Number below.
EXISTING
PATIENT?
Yes No
(check
one)
4th Ply: Employer3rd Ply: Employee2nd Ply: Cigna Eligibility Services / CDH / Dental Claim OfficeDISTRIBUTION: Original: Cigna HealthCare / Eligibility Services
(Street)
.
I agree, for myself and my covered dependents, that, in the event any health services provided are the primary responsibility of any other party by way of other
group health coverage or by the act or omission of another person, I will fully inform the health plan and will execute such assignments, liens or other documents
which may be necessary to enable the health plan to recover the value of the services provided. I further agree that in the event I or any of my covered dependents
collect benefits or damages from any other party who has primary responsibility for services provided by the health plan, I will immediately reimburse the health plan
to the extent of services provided and to the extent permitted by state law.
AUTHORIZATION TO DEDUCT CONTRIBUTIONS
I authorize deductions from my earnings of the required contributions, if any, toward the cost of the coverage. This authorization applies only if employee contributions
are required.
FRAUD WARNING
By allowing an individual to enroll in the health plan, other than during the open enrollment period, Cigna Health and Life Insurance Company and its affiliates do not
waive any terms of its contract. Further, by allowing an individual to enroll in the health plan, other than during an open enrollment period, Cigna Health and Life
Insurance Company and its affiliates do not thereby express any opinion regarding the appropriateness of the change under Section 125 of the Internal Revenue
Code or the terms of the employer’s Section 125 Plan.
Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing
any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.
SPECIAL PROVISIONS FOR EMPLOYERS WITH SECTION 125 PLANS
In Connecticut, HMO plans are offered by Cigna HealthCare of Connecticut, Inc.
.
PROVISIONS
In Connecticut, the DHMO (Cigna Dental Care )plan is underwritten or administered by Cigna HealthCare of Connecticut, Inc. The Cigna Dental PPO and Indemnity
plans are underwritten or administered by Cigna Health and Life Insurance Company, with network management services provided by Cigna Dental Health, Inc.
.
"Cigna," "Cigna Choice Fund," "Cigna Care Network" and "Cigna Dental Care" are registered service marks, and the “Tree of Life” logo and “Cigna HealthCare” are
service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or
through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health
and Life Insurance Company, Cigna HealthCare of Connecticut, Inc. and Cigna Dental Health, Inc.
2012 Cigna
®
©
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