ࡱ> ;=89:)` .jbjbj B0ar"qqq8rr4(2.u{"||||v~"T$¬h*5Љ||ЉЉ5||JЉ"||ЉhǤ|"u |9 q;`0'" ǤǤtv`vvv55vvvЉЉЉЉ((($Iq(((qd~@ GROUP ENROLLMENT/CHANGE REQUEST [Carrier Logo]Group Information to be completed by [Employer]: [Carrier Name]Group Name:[Group Number]: [Class Code]:A. Type of Activity to be completed by [Employer]. Refer to instructions [on back] before completing this form. Print clearly. Activity Check all that applyEffective Date/ Date of EventDate of Hire/Reason for Change1. ADD FORMCHECKBOX  Enrollment of a new [Enrollee/Subscriber]  FORMCHECKBOX  Add Spouse[/Civil Union Partner] [ FORMCHECKBOX Civil Union Partner]  FORMCHECKBOX  Add Domestic Partner  FORMCHECKBOX  Add Dependent Child  FORMCHECKBOX  Add Over-Age Child as a Dependent Under 31(and complete section A 4) _____/_____/_____ _____/_____/_____ [_____/_____/_____] _____/_____/_____ _____/_____/_____ _____/_____/_____Date of Hire: _____/_____/_____ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ ________________________________________________________2. REMOVE FORMCHECKBOX  [Employee] Withdrawal/Termination  FORMCHECKBOX  Remove Spouse[/Civil Union Partner] [ FORMCHECKBOX Civil Union Partner]  FORMCHECKBOX  Remove Domestic Partner  FORMCHECKBOX  Remove Dependent Child  FORMCHECKBOX  Remove Over-Age Child as a Dependent Under 31 _____/_____/_____ _____/_____/_____ [_____/_____/_____] _____/_____/_____ _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ ________________________________________________________3. OTHER CHANGE FORMCHECKBOX  Name Change  FORMCHECKBOX  Change Plan  FORMCHECKBOX  Other  FORMCHECKBOX  [Add/Change Office ID Numbers: Primary/OB/Gyn/ Dentist]_____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________4. COVERAGE CONTINUATION FORMCHECKBOX  For Employee  FORMCHECKBOX  Total Disability*  FORMCHECKBOX  COBRA/NJSGC Length of Continuation (in months):  FORMCHECKBOX  18  FORMCHECKBOX  29 Date of Loss of Coverage: ___/___/___ Qualifying Event #:____________** Date of Qualifying Event: ___/___/___ [Billing:  FORMCHECKBOX  Group  FORMCHECKBOX  Home (Section B)] *Attach proof of disability FORMCHECKBOX  For Spouse/Civil Union Partner* Length of Continuation (in months):  FORMCHECKBOX  18  FORMCHECKBOX  36 Date of Loss of Coverage: ___/___/___ Qualifying Event #:_________________** Date of Qualifying Event: ___/___/___ [Billing:  FORMCHECKBOX  Group  FORMCHECKBOX  Home (what address?)  FORMCHECKBOX  Section B OR  FORMCHECKBOX  Section [E]] *Civil union partners are eligible to make an election pursuant to NJSGC, if applicable.  FORMCHECKBOX  For Dependent or Over-age Child  FORMCHECKBOX  COBRA/NJSGC Length of Continuation (in months):  FORMCHECKBOX  18  FORMCHECKBOX  36 Loss of Coverage: ___/___/___ Qualifying Event #:__________________** Date: ___/___/___  FORMCHECKBOX  Dependent Under 31 Qualifying Event #:__________________** [Billing:  FORMCHECKBOX  Group***  FORMCHECKBOX  Home (what address?)  FORMCHECKBOX  Section B OR  FORMCHECKBOX  Section [F]] **Qualifying event #s: see list in Instructions. [ ***Billing through the group for a Dependent Under 31 Continuation Election requires agreement by the employer at Section [J] .]  B. [Employee] Information to be completed by the [Employee] Name (Last, First, MI): SSN:Home Street/Apt:________________________________________________________________________________________ Street/Apt:________________________________________________________________________________________ City:___________________________________________________ State:_____ Zip Code: _____________________ Birthdate (mm/dd/yyyy):  FORMCHECKBOX  Male  FORMCHECKBOX  FemalePhone: (_____)________________ [Email: _______________________________]Work [Employer] Name:__________________________________________________________________________________ Address:__________________________________________________________________________________________ City:___________________________________________________ State:_____ Zip Code: ______________________ Phone: (_____)__________________ [Email: _________________________________] Employment Date: _____/_____/_____ Hours worked per week:_________Activity FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Continuation  FORMCHECKBOX  Other Change If a name change, indicate prior name:[Primary Loc #:]________________________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No][Ob/Gyn Loc #:]________________________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No] [Dentist Loc #:]________________________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No]Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ____________________________________________________________ Policy #: ________________________________________ Medicare ID#, if any: [Other Rx Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ____________________________________________________________ Policy #: ___________________________________________ Medicare ID#, if any: ]C. Plan Option to be completed by the [Employee] Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status]D. Other Individuals Covered to be completed by the [Employee] Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage. Attach additional pages if necessary, with your signature and dated. [Attach proof of disability.] 1. Spouse; Domestic or Civil Union Partner2.Child3. Child4. Child FORMCHECKBOX Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX Continue Spouse  FORMCHECKBOX Continue CU Partner (NJSGC) FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other  FORMCHECKBOX  Continue  FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX  Continue FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX  ContinueName (last, first, MI) L:________________________________ F:________________________________ MI:Name (last, first, MI) L:_________________________________ F:_________________________________ MI:Name (last, first, MI) L:_________________________________ F:_________________________________ MI:Name (last, first, MI) L:_______________________________ F:_______________________________ MI:Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy):  FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  FemaleSocial Security Number: Social Security Number: Social Security Number: Social Security Number: Other Health Coverage  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: _________________________________ Policy #: _________________________ Medicare ID #:Other Health Coverage  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: ___________________________ Medicare ID #:Other Health Coverage  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: ___________________________ Medicare ID #:Other Health Coverage  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: _________________________________ Policy #: _________________________ Medicare ID #:[Other Rx Coverage:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: __________________________________ Policy #: __________________________ Medicare ID #:] [Other Rx Coverage:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: ___________________________ Medicare ID #:] [Other Rx Coverage:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: ___________________________ Medicare ID #:] [Other Rx Coverage:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: _________________________________ Policy #: _________________________ Medicare ID #:] [Primary Care Provider: NPI#:____________________ Address:___________________________ __________________________________ ______________zip+4_______________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI:______________________ Address:____________________________ ___________________________________ _______________ zip+4______________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI#:_____________________ Address:____________________________ ___________________________________ _______________ zip+4_______________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI#:______________________ Address:__________________________ _________________________________ __________________ zip+4_ ________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Ob/Gyn Office NPI#:______________________ Address:___________________________ __________________________________ ____________________ zip+4_________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:____________________ Address:____________________________ ___________________________________ ____________________ zip+4__________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:______________________ Address:____________________________ ___________________________________ ___________________ zip+4 _________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:______________________ Address:__________________________ _________________________________ ______________________ zip+4______ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX  NA]][Dentist Office NPI#:_____________________ Address:___________________________ __________________________________ ____________________ zip+4_________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Dentist Office NPI#:____________________ Address:____________________________ ___________________________________ _____________________ zip+4_________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Dentist Office NPI#:______________________ Address:____________________________ ___________________________________ ________________________ zip+4_____ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Dentist Office NPI#:______________________ Address:__________________________ _________________________________ _____________________ zip+4_______ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]]Employed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, complete Section [E]1 If last name is different from [Employees], please explain: ___________________________________ ___________________________________If last name is different from [Employees], please explain: ___________________________________ ___________________________________If last name is different from [Employees], please explain: _________________________________ _________________________________Home or billing address same as [Employee]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [E]2Living with [Employee]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [F] Living with [Employee]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [F]Living with [Employee]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [F]E. Additional Spouse/Civil Union Partner/Domestic Partner Information to be completed by [Employee] If not applicable, please mark as NA.1. Employer Name:________________________________________________________________________________ Employer Address:______________________________________________________________________________ City, State, Zip Code:____________________________________________________________________________ Employer Phone: ( )2a. Street/Apt:______________________________________________________________________________________ Street/Apt:______________________________________________________________________________________ City, State, Zip Code:__________________________________________________________________________2b. Please explain why the address is different: _____________________________________________ _____________________________________________ F. Additional Child Information to be completed by [Employee]. Provide information below about children listed in Section D, if they have a different address from the employee. If multiple children are at an address, you may list them together. Attach additional pages as necessary, signed and dated.  Name(s):________________________________________________________________ Street/Apt:_______________________________________________________________ Street/Apt:_______________________________________________________________ City, State, Zip Code: _____________________________________________________ Reason:_________________________________________________________________ Name(s):_______________________________________________________________ Street/Apt:_____________________________________________________________ Street/Apt:_____________________________________________________________ City, State, Zip Code:_____________________________________________________ Reason:________________________________________________________________G. Race/Ethnicity to be completed by the [Employee], at his/her option. NOTE: your response is appreciated but NOT required! Choose a category that most closely describes you:  FORMCHECKBOX  American Indian or Alaskan Native  FORMCHECKBOX  Black, not of Hispanic origin  FORMCHECKBOX  Hispanic  FORMCHECKBOX  Asian or Pacific Islander  FORMCHECKBOX  White, not of Hispanic origin H. [Employee] Signature I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form. I authorize deductions from my earnings for any contributions required from me. Signature: _________________________________________________________________________ Date: ________________________________I. Over-Age Childs SignatureI represent that all the information supplied in this application regarding the [Dependent Under 31] Continuation Election is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form. [I hereby agree to make contributions required from me for the Dependent Under 31 Continuation Election.] Signature: _________________________________________________________________________ Date: ________________________________ J. [Employer] VerificationThe requested activity is believed eligible and is approved by the [Employer]. [In addition, the [Employer] consents to payroll deduction for Dependent Under 31 Continuation Election:  FORMCHECKBOX  Yes  FORMCHECKBOX  No] Employer Representative: _____________________________________________________ Date: _______________________________________ Representatives Title: _________________________________________________________CONDITIONS OF ENROLLMENT -- [APPLICANT] ACKNOWLEDGEMENTS AND AGREEMENTSOn behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that: I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give [Carrier Name], or any consumer reporting agency acting on behalf of [Carrier Name], information pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from the date I sign this Enrollment/Change Request form, unless revoked at an earlier date. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that [Carrier Name] has taken in reliance on the authorization. I understand I may receive a copy of this authorization if I request one. I agree [Carrier] will provide coverage in accordance with the terms of the contract for the group [plan] [policy]. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the group [plan] [policy] if premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the premium, as appropriate. INSTRUCTIONS[Employers] You must complete the [Employer] Group Information and sections A and J in order for this application to be processed. [Employees] You must complete sections B through H and submit the signature of each Over-Age Child for which a Dependent Under 31 Continuation Election is made in accordance with Section I in order for this application to be processed. Please PRINT except when a signature is requested. If a dependent is disabled and you want to continue his or her coverage beyond age 26, you do not have to make a COBRA/NJSGC or Dependent Under 31 election. Instead, select Other in Section A3, and attach proof of disability. For provider addresses, include the zip code plus the four digit extension (11 digits) You can obtain the providers correct names and addresses from the appropriate provider directory. You may also obtain each providers NPI number [from the provider directory] [or] [and] [at: URL] [or] [and] [by contacting the provider directly.] Providers with multiple office locations and individual providers who belong to more than one practice or provider entity may have more than one NPI number. You should confirm the correct NPI number for the specific provider and office location where you will be seen by contacting that office directly.Qualifying Events COBRA and NJSGC C1. Termination of job or reduction in hours C2. Employee enrollment in Medicare (COBRA only) C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC) C4. Death of employee C5. Loss of dependent child status under the plan C6. Disability (occurring subsequent to another qualifying event) Dependent Under 31 D1. Loss of dependent status and otherwise eligible D2. Reestablish eligibility: residency D3. Reestablish eligibility: nonresident full-time student D4. Reestablish eligibility: change in marital status D5. Reestablish eligibility: change in parental status D6. Reestablish eligibility: termination of other coverage Carrier instructions (not to be included in the Enrollment/Change Request form when printed by the carrier) Carrier should insert its logo and name where indicated, or leave the table blank, or blacked-out. Carrier must replace bracketed text carrier name with carriers full name throughout the document. If the carrier refers to the Employer using another term such as Planholder or Contractholder or some similar term, replace the term Employer with such other term throughout the document. If the carrier refers to Group Number/Class Code using some other term such as Policy Number, Control Number or some similar term, replace the term Group Number/Class Code with such other term. Replace on back with appropriate directions if the instructions are not provided on the reverse side. If the carrier refers to the Enrollee/Subscriber using another term such as Member or Applicant or some similar term, replace the term Enrollee/Subscriber with such other term throughout the document. In Section A1 and 2, the carrier may choose to put Civil Union Partner on the same line as Spouse, or insert new lines for Civil Union Partner separately. In Section A, omit Add/Change Office ID Numbers options if carrier does not offer such options. In Section A, the continuation billing options should be omitted if the carrier does not offer such options. In addition, the phrase ***Billing through the group for a Dependent Under 31 Continuation Election requires agreement by the employer at Section J if the carrier does not offer the Integrated continuation coverage option. In Section B, references to the employees e-mail address should be omitted if the contact option is not offered. At Section B and D, references to primary, ob/gyn and dentist selections should be omitted if selections are not an option or a requirement. If a carrier does not assign numbers for each office location, then carriers may indicate that LOC refers to the office location in the selection information, and request that enrollees identify a name for the office location. However, carriers should not request complete office address locations. At Section B and D, reference to current patient information should be omitted if the carrier does not require it. At Section C, insert carrier plan options and deductibles, coinsurance or copayment options, and provide directions for employee/enrollee selections of options as appropriate. At Section D1, the carrier may elect not to reference Domestic Partner if an employer does not permit coverage of Domestic Partners. At Section D1, the carrier may indicate that continuation is an option for Spouse only for groups subject ONLY to COBRA. At Section D, requests for information about other prescription drug coverage are optional. At Section D, if the carrier does not require proof of disability, omit the directions to attach proof. At Section E, carriers may omit Domestic Partners if the employer does not allow coverage for domestic partners. At Section J, omit In addition, the [Employer] consents to payroll deduction for Dependent Under 31 Continuation Election:  FORMCHECKBOX  Yes  FORMCHECKBOX  No if the carrier does not offer the Integrated continuation coverage option. At Instructions, if you require selection of health care providers, insert appropriate information on how to obtain correct NPI numbers. Note that indicating information is available only through a website is not appropriate. At the Footnote, if a carrier does not utilize an Internal Carrier Form Number, the carrier may omit the reference.     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