Slappey and Sadd, LLC - 2025 Benefits Guide

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 |

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