A. Transaction Information
1. Enrollment
Basic Life
Supplemental Life
Supplemental AD&PL/AD&D
AD&PL/AD&D
Requested Employee Coverage
Basic Dependent Life
Supplemental Dependent Life
Supplemental Dependent AD&PL/AD&D
Basic Dependent AD&PL/AD&D
Requested Dependent Coverage
10. Employee Coverage Amounts - Based on the requirements of your Plan, you may have to submit evidence of good health. (Life Insurance ONLY)
Basic Life Amount Supplemental Life Amount Basic AD&PL/AD&D Amount Supplemental AD&PL/AD&D Amount
$$$
$
D. Covered Dependents - Complete only if Dependent Coverage is offered under your Plan.
(A)dd/New
(C)hange
(R)emove
Dependent Name (First, Middle Initial, Last)
Social Security Number
(If dependent has no SSN, write
"None")
Birthdate
MM / DD / YYYY
Relation.
Code
Basic Dependent
AD&PL/AD&D Amount
/ /
/ /
/ /
- -
- -
- -
- -
Supplemental Dependent
AD&PL/AD&D Amount
Yes No
Supplemental Dependent
Amount
Basic Dependent
Amount
$
$
$
$
$
$
$
$
$
$
$
$
$
$$
$
Check this box if you are refusing coverage for your dependents.
Special
Remarks
Full Beneficiary Name (First, Middle, Last)
11. Beneficiary Designation - If more than one beneficiary, use Special Remarks. Dependent coverage Beneficiary is always the Employee. (Life Insurance ONLY)
Social Security Number of Beneficiary
- -
Relationship to Employee
E. Certification - Signatures Required
My signature below signifies my agreement with the statements and authorization under Certification and Authorization on the back of this form.
1. Employee Social Security Number
C. Employee Information - Please Print all Information
6. Employee Home Address (Number, Street, Apt. No., City, State, ZIP Code)
1. Employer Name - Full Name of Business or Organization
2. Control No.
5. Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization
B. Employer Information - Please Print all Information
Account 3. Plan Number
4. SFO
Suffix
6. Claim Office Code 7. Customer Code (Optional)
X
1. Employee Signature
(Required)
Date
X
2. Employer Signature
(Required)
Date
/ /
GR-67269-91 (12-01)
Employee's E-mail Address:
V1 R-POD
7. Employee Annual Earnings
$
9. Work State
8. Occupation/Title
Short Term Disability
Long Term Disability
Student Age
19 or Older
(Life Insurance ONLY)
2. Employee Name (Last, First, M.I)
Employee *
2. Termination (Cancel)
Add Dependent(s)
(Life ONLY)
Plan Change
Increase/Decrease Benefit Amount*
Remove Dependent(s)
(Life ONLY)
3. Change (*Provide explanation in Section D, Special Remarks.)
Other*
Employee must be
enrolled for dependent(s)
to have coverage.
*
Effective Date (MM/DD/YYYY)
Effective Date (MM/DD/YYYY)
Life and Disability Enrollment/Change Request
Aetna Life Insurance Company
- -
New Employee
Retiree
Rehire/Reinstatement
Date of Hire (MM/DD/YYYY)
Effective Date (MM/DD/YYYY)
5. Telephone Numbers
3. Birthdate (MM/DD/YYYY)
4. Sex
( )
-
Home
/ /
( )
-
Work
Please make a copy for your records. visit us at www.aetna.com
Eastern Michigan University
#473398
203
140 McKenny Hall, Ypsilanti, MI 48197
Instructions -
Instructions are provided only for those fields which are not self-explanatory or for which you may need additional information.
A. Transaction Information
Make sure you complete the
Effective Date in Section A
- Transaction Information.
Make sure you read
Section E. Sign Name
and date.
To Enroll
Complete Effective Date and Date of Hire in Section A -
Transaction Information.
Check the box(es) applicable to the benefit(s) you wish to enroll
for in Section A - Transaction Information, Number 1 -
Enrollment, Requested Employee Coverage and Requested
Dependent Coverage.
Complete all blank fields in Section B - Employer Information
and Section C - Employee Information.
Complete Section D - Covered Dependents for all dependents for
whom you are electing coverage. Complete ALL items for each
individual listed.
Make sure you read Section E - Certification. Sign Name and
Date.
B. Employer Information
The Servicing Field Office
(B4) and Claim Office Code
(B6) are assigned by Aetna.
Control, Suffix and Account - If this information is not preprinted, provide the complete Control, Suffix and Account numbers.
Plan Number - If this information is not preprinted, refer to the Plan Sheet to determine the correct Plan Number.
Customer Code (Optional) - Provide an identifying Customer Code for the employee only if you had elected to provide this information.
B2.
B3.
B7.
C. Employee Information
To be completed by the
Enrollee.
Birthdate - Date of birth should include four digit year of birth.
Employee Coverage Amounts - Consult your Benefits Administrator to identify which earnings/insurance amounts need to be reported. Complete
the appropriate box and enter the rounded dollar amount.
Beneficiary Designation - Full Beneficiary Name (First, Middle and Last), Social Security Number and relationship of the person to whom benefits
will be paid in the event of your death.
C3.
C10.
C11.
D. Covered Dependents
To be completed by
Enrollee.
List only those individuals
for whom you are electing/
changing coverage and
complete ALL items for
each individual listed.
Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an individual.
Name - This must be completed for all individuals for whom you are electing or changing coverage. Please complete ALL items in Section D for
each individual listed. Attach another form if you are requesting coverage for additional dependents.
Relationship Code - Use ONLY: H=Husband, W=Wife, N=Divorced Spouse, S=Son, D=Daughter, Y=Sponsored Male, X=Sponsored Female. If the
dependent is NOT a biological or legally adopted child, please indicate relationship to employee in Special Remarks.
Birthdate - Date of birth should include four digit year of birth.
Student Age 19 or Older - Defined as: Unmarried dependent child age 19 or older (refer to your Summary of Coverage), regularly attends school
and depends solely on the enrollee for support. Member Services may request that you provide proof from the educational institution.
Insurance Amounts - Consult your Benefits Administrator to identify which insurance amounts need to be reported. Complete the appropriate
box(es).
E. Certification
Signatures Required
Read the information contained above the space provided for your signature in Section E and the information on the back of the form.
Sign name and date the form.
To Terminate (Cancel)
Complete Effective Date in Section A - Transaction Information,
Number 2 and check appropriate box.
Complete all blank fields in Section B - Employer Information and
Section C - Employee Information.
Make sure you read Section E - Certification. Sign Name and Date.
To Change
Complete Effective Date in Section A- Transaction Information, Number
3 and check appropriate box(es).
Complete blank fields in Section B - Employer Information (if
applicable).
Complete Section C - Employee Information.
Indicate change(s) in appropriate Section(s) (B, C, D) and circle.
Make sure you read Section E - Certification. Sign Name and Date.
Misrepresentation
Certification
I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that this
insurance is subject to all of the terms of the Plan of Insurance contained in the group policy and summarized in the
announcement material provided me and the certificate issued to me.
I understand that the effective date of insurance for myself or for any of my dependents is subject to my being actively at work
on that date and that the effective date of insurance for any of my dependents is also subject to the dependent health condition
requirements of the Plan. Further, I understand that any insurance subject to evidence of good health or medical information
will not become effective until Aetna gives its written consent.
I understand that, in the event I fail to sign this form within 31 days of the effective date of eligibility or that for any reason
Aetna does not receive notice of the Enrollment/Change Request within a reasonable time following the event, my and my
dependents' eligibility may be affected.
I request my employer to arrange for the issuance of Group Life Coverage for which I am or may become eligible and authorize
deductions of the required contributions from my earnings.
Misrepresentations: 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.
Attention California Residents: For your protection, California law requires notice of the following: Any person who
knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing any materially
false or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison, and substantial
civil penalties. Many other states have similar laws.
Attention Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a
claimant regarding insurance proceeds must be reported to the Insurance Division.
Attention Florida and Virginia Residents: Any person who knowingly and with intent to defraud or deceive any insurer files
a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the
third degree.
Attention 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.
(12-01)
V1
GR-67269-91