Visit us at Humana.com
Small Group Employee Enrollment Form - 1-50 Employees
GEORGIA
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in the Small Group Employee Enrollment Form as “Humana”. To elect primary care physician or dentist, please complete reorder GA-51340-PP. HMO and POS plans offered by Humana Employers Health Plan of Georgia, Inc., and/or insured or administered by Humana Insurance Company. PPO and Indemnity Medical plans and Life plans insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company. PrePaid Dental Plans offered by Humana Employers Health Plan of Georgia, Inc. Vision plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company.
Please print clearly and fill in each applicable circle.
Proposed effective date: _ _ / _ _ / _ _ _ _
Employer / Group name
Employer / Group city
State
Qualifying Event Instructions m New business enrollment m New hire / Newly eligible
Date of Qualifying Event: _ _ / _ _ / _ _ _ _
m Open Enrollment event m Rehire / Reinstatement
m Dependent birth or adoption m Marital status change
m Loss of coverage
m Other___________________
Enrollment information
Social Security Number N/A (complete in Employee/ Individual Information section.)
Disabled? If yes, indicate reason below.
Relationship
Last name, First name MI
Gender Date of birth m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____
m Y m N m Y m N m Y m N m Y m N m Y m N m Y m N
Employee / Individual
Spouse / Domestic Partner
Child / Dependent Child / Dependent Child / Dependent
Other (specify):
Employee / Individual Information
Hours worked per week:
Date of full time hire: _ _ / _ _ / _ _ _ _
Social Security Number
Street address
APT / Suite / Box
City
State
ZIP code
Phone # ( )
Language: m English m Spanish m Other E-mail address Occupation Are you actively at work? m Y m N If not, reason: m Retiree m COBRA Other: _______________ Annual salary $ Prior / Existing Coverage: IMPORTANT - DO NOT cancel any existing coverage until you receive written notification from Humana of your acceptance for coverage. Medical 1. Prior medical coverage during the past 18 months (individual or other group coverage)? m N m Y Prior medical insurance carrier name Policy # Prior coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _ 2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)? m N m Y Other medical insurance carrier name Policy # Other coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
3. Medicare Employee / Individual coverage: m N m Y Medicare ID
Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _ Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
Medicare ID
Spouse coverage: m N m Y
GA-72000 10/2015
1
Reorder# GA-52000-SB 1/2018
17 Slappey & Sadd, LLC 2025 Benefits Guide |
Made with FlippingBook - professional solution for displaying marketing and sales documents online