Green MD LLC – 2021

Name (required)

Email Address (required)

Phone Number (required)

Gender (required)

MaleFemale

Social Security Number

Date of Birth

Mailing Address (street)

City

State

Zip Code

Date Employed Full Time

Hours Worked Per Week

Annual Income

Job Occupation/Class

Location

Do you have an eligible spouse or domestic partner or child(ren)?

YesNo

Payment Mode

monthlysemi-monthlyweeklybi- weekly

Employer Zip

Employer County

Eligible Dependent Information (Complete if you are electing benefits for your spouse or domestic partner or children)

Name

Date of Birth

Gender MaleFemale

Social Security Number

Relationship SpouseDomestic Partner

Name

Date of Birth

Gender MaleFemale

Social Security Number

Relationship ChildFoster Child*Disabled Child

Name

Date of Birth

Gender MaleFemale

Social Security Number

Relationship ChildFoster Child*Disabled Child

Name

Date of Birth

Gender MaleFemale

Social Security Number

Relationship ChildFoster Child*Disabled Child

Name

Date of Birth

Gender MaleFemale

Social Security Number

Relationship ChildFoster Child*Disabled Child

*If you checked foster child, was the child placed with you by an authorized state placement agency or by order of a court? YesNo

**When your child, who is developmentally or physically disabled, reaches/exceeds the maximum age, an Application to Continue Disabled Child form must be completed and reviewed to determine eligibility. Is your spouse or domestic partner employed by this company? YesNo

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Coverage Opt-ins

Desired Health Plan And Coverage Opt-ins

G653CHCS663CHCG664ADTS9J7ADT

Who is covered?
Employee OnlyEmployee and SpouseEmployee and ChildrenEmployee and Family

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Important: You must elect Employee coverage in order to elect the coverage for your dependent(s).

*If enrolling a Domestic Partner, please attach a separate Declaration of Domestic Partnership/Enrollment Form Addendum (GP60480).

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Declining Coverage

Important: If declining any coverage for yourself or any dependent, give reason. Covered under:

Spouse's or Domestic Partner's Group InsuranceIndividual InsuranceOther Coverage Offered by My EmployerOther

Please state your other coverage:

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Primary Care Physician

If selecting an HMO plan, please list the primary care physician for every covered family member.
Employee Primary Care Physician:  
Spouse Primary Care Physician:    
Dependent Primary Care Physician:
Dependent Primary Care Physician:
Dependent Primary Care Physician:
Dependent Primary Care Physician:
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Employee Agreement (Read and sign)

I understand and agree with the following statements:
• My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified when a claim is filed.
• If I refuse dental coverage, I and my dependents may enroll later but this will affect the level of benefits.
• If I refuse coverage, I cannot enroll after retirement.
• If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise.
• If the group policy requires my contribution, I authorize my employer to deduct from my pay.
• I represent all information on this form and attachments is complete and true to the best of my knowledge. They are part of this request for coverage. I agree insurance carrier is not liable for a claim before the effective date of coverage and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During the first two years coverage is in force, fraud or intentional misrepresentations can cause changes in my coverage, including cancellation back to the effective date.
• Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud.
• Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I also understand collection of social security numbers for myself and/or my dependents will be used by insurance carrier only as allowed by law.
• I authorize insurance carrier to release data as required by law. If signed in connection with an application, reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for information not yet obtained. I understand data obtained will be used by insurance carrier for claims administration and determining eligibility for life, disability and critical illness coverage. Information will not be used for any purposes prohibited by law.

A copy of this form will be as valid as the original.

I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from insurance carrier.

Digitally Sign and Agree:

Name:

I agree.I do not agree.
Date:

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