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.
