First name:
Last name:
Dental 1. Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y 2. Prior orthodontia coverage in the past 12 months? m N m Y Prior dental 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 _ _ / _ _ / _ _ _ _
Prior carrier phone # (
)
Coverage Options Medical
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Health Savings Account Class/Div: If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details. Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can find additional information on HSAs on Humana.com. Select the Quick Link for Spending Account information on the Member page. Do you elect the Health Savings Account? m N m Y (If no, complete waiver.) Group #: Benefit #: Beneficiary for this account will be the employees / individual’s estate. You may change beneficiary information on file with the bank that administers the HSA once the account is established.
Dental
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly)
Basic Life /Accidental Death and Dismemberment
Group #:
Benefit #:
Class/Div:
Class (employer will provide you with this information, if needed)
Basic dependent life m N m Y (If no, complete waiver.)
Voluntary Life Accidental Death and Dismemberment
Group #:
Benefit #:
Class/Div:
Amount (min $15,000) $
Voluntary employees / individual life coverage m N m Y
Voluntary spouse life coverage? m N m Y Amount (min $5,000) $
Voluntary child(ren) life coverage? m N m Y
Vision
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly)
Beneficiary Information for Life Primary beneficiary name (Last, First MI)
Relationship to Employee / Individual
Secondary beneficiary name (Last, First MI)
Relationship to Employee / Individual
Evidence of Health Status - Do not submit more than 90 days prior to the effective date. Complete this section if you are selecting Life over the guarantee issue amount. ALL MEDICAL QUESTIONS SHOULD BE ANSWERED IN RELATION TO TREATMENT OR DIAGNOSIS MADE BY A MEDICAL PROFESSIONAL OR PHYSICIAN AND ARE LIMITED TO THE LAST 10 YEARS UNLESS OTHERWISE INDICATED. 1. Is anyone on this application currently taking any prescribed medication for a recurrent condition?
m N m Y m N m Y
2a. In the past 12 months has any applicant used any tobacco product? If yes, applies to: m Employee m Spouse/Domestic Partner m Other m Child/Dependent
2b.
Is any applicant currently a smoker? If yes, applies to: m Employee m Spouse/Domestic Partner m Other m Child/Dependent
m N m Y
18 | Slappey & Sadd, LLC 2025 Benefits Guide GA-72000 10/2015
2
Reorder# GA-52000-SB 1/2018
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