Conditions of enrollment (Continued)
I represent that all information supplied in this form is true and complete. I have read and agree to the conditions of enrollment and misrepresentation
on this Employee Enrollment / Change Form.
I understand that if I don’t sign this form within 31 days or Aetna does not receive the request within a reasonable time, my eligibility may be affected.
I am employed by the employer shown on page 1. I am working full time or at least 25 hours a week for this employer at the regular place of business. I
authorize deductions from my earnings for any contributions required for coverage. I agree to make any necessary payments required for coverage.
I have read and understand the information provided in the Disclosure section of this form.
To receive documents online, please visit your secure member account at Aetna.com.
Misrepresentation: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any person who knowingly and with intent
to defraud any insurance company or other person files an enrollment form 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.
Please sign here ONLY if you are enrolling in coverage for yourself
Employee email
Date (Month/Day/Year)
and / or dependents.
Employee signature (required)
7000-2-SG
SG (1-50) GA V2 B
7000-2 (6-18)
5
15 Slappey & Sadd, LLC 2025 Benefits Guide |
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