Georgia Small Group Employee
Enrollment/Change Form
Aetna Life Insurance Company
Aetna Health Inc.
Group number
INSTRUCTIONS: You must complete this enrollment form in full. If you do not, we will return it to you, and
that can delay its processing. You alone are responsible for its accuracy and completeness. If you are
Aetna member ID number (if available)
declining coverage, you must complete Section B. Please use only black ink to complete this form.
Company name
Effective date
Employee termination date
Add spouse
New hire
Add domestic partner
Rehire / reinstatement
Remove spouse
Add dependent child
New group enrollment
Remove domestic partner
Change of coverage
Late enrollment
Remove dependent child
Date of hire
Waiver
Name change
Cancel coverage
Open enrollment
Other
Loss of coverage
Address change
COBRA State continuation for:
Employee Dependent
Length of continuation:
18 months 36 months Other
Qualifying event
Original qualifying event date
Loss of coverage date
A. Employee information – You must complete this section. Please print clearly.
Social Security number
Last name, first name, middle initial
Job title
Home address
Apt. number City, state
ZIP code
Work address
City, state
ZIP code
Home telephone
Work telephone
Primary language spoken
Number of dependents, including spouse or
(optional)
domestic partner, enrolling for coverage
-
-
(
)
(
)
Salary
Number of hours
Check one:
Hourly
worked a week
Full time
1099
Seasonal
COBRA
Weekly
$
Part time
Retiree
Temporary
Union
Monthly
B. Declining coverage – Check all that apply.
I understand I am eligible to apply for this coverage through my employer. However, I am declining the coverage I checked below:
Reason for declining coverage
Employee:
Dental
Parental group coverage
Indian Health Services
Vision
Spouse / domestic partner
TRICARE / Military coverage
group coverage
Individual coverage – On Exchange
Spouse / domestic
Dental
Medicare
Individual coverage – Off Exchange
partner:
Vision
Medicaid
Another group plan provided by
Retiree coverage
my employer
Children:
Dental
COBRA coverage
Do not want
Vision
Insurance through another job
Other
I certify I have been given the right to apply for this coverage. However, I am declining coverage as noted above. By declining this group coverage, I
acknowledge that I and / or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.
Date (Month/Day/Year)
Please sign here ONLY if you are declining coverage for yourself and / or dependents.
I am declining coverage. Employee signature: X
Please PRINT employee name:
7000-2-SG
1
SG (1-50) GA V2 R-POD B
7000-2 (6-18)
11 Slappey & Sadd, LLC 2025 Benefits Guide |
Made with FlippingBook - professional solution for displaying marketing and sales documents online