B. Decline / waive – To be completed if medical coverage is declined or refused by an eligible employee and / or their eligible family members.
I acknowledge I have been given the right to apply for this coverage; however, I am electing not to enroll. 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. I and / or my dependents have made this decision of my / their own accord with no pressure from my employer, my employer’s agent or the
insurance carrier.
Please sign here ONLY if you are declining coverage for yourself and / or dependents.
Medical coverage declined for:
Myself
Spouse / civil union / domestic partner
Children
X Employee signature
Date (Month/Day/Year)
C. Medical coverage selection
Plan Option
D. Other medical coverage – List any individuals who will have other health insurance at the same time as this coverage.
Name of individual
Carrier Name
Name of individual
Carrier Name
E. Medicare coverage – List individuals covered by Medicare.
Name of individual
Medicare Part A
Medicare Part B
Medicare Part D
Over Age 65
Disability
End-Stage Renal Disease Effective Date
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
F. Individuals enrolling – List individuals enrolling or adding, changing or removing coverage. If more space is needed check here
and use a separate sheet of paper.
Weight Tobacco or nicotine
Dependent information
Last name, first name, middle initial
Sex
Social Security
Birthdate
Height
(A) dd
use (including
(List city, state and ZIP code for any
(M/F)
number
(MM/DD/YYYY)
(C) hange
E-cigarette devices)
dependent living at another address
(R) emove
Employee
NA
Yes
No
1.
Spouse
Civil union
Domestic partner
Yes
No
2.
Child
Stepchild
Other
Yes
No
3.
Child
Stepchild
Other
Yes
No
4.
Child
Stepchild
Other
Yes
No
5.
G. Health Questionnaire – Complete for all individuals enrolling for coverage.
Have you or anyone applying for coverage consulted with or been examined, diagnosed, or treated by any health care professionals during the last five (5) years for any illness, injury or
health condition in any of the categories listed below? If “yes,” please check the box that most appropriately describes the condition(s) and explain fully below (page 4).
1. Cancer / tumor / cyst
Yes
No
Brain
Breast
Esophagus
Stomach
Colon
Leukemia
Lymphoma
Multiple myeloma
Kidney
Liver
Lung
Melanoma
Pancreas
Prostate
)
Testicular
Cervical
Ovarian
Uterine
Throat
Thyroid
Other cancer (type / location
)
Non-malignant tumor (type / location
Diagnosis date
Cancer stage (0-4)
(if known) Cancer category (In situ, localized, regional, distant)
(if known)
Treatment:
Surgery date
Chemo timeframe
Radiation timeframe
Remission
Yes
No
If yes, provide date of remission
Continued on next page
GR-69452 (3-24)
2
SG AFA IMQ
A
6 | Slappey & Sadd, LLC 2025 Benefits Guide
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