(DO NOT STAPLE)

Employee Enrollment Form

To speed the enrollment process, please be thorough and fill out all sections that apply.

Group
To BeName
Completed by Employer Requested Effective Date of Coverage/Date of Change / /
Group Name/Policy Number

Date of Hire / / Reason for Application Employee Type

Position/Title  New Group Plan  New Hire (Check all that apply)
 Life Event/Date_______  Annual  Active  COBRA  State Continuation
 Status Change_______ Open Start dt ____/____/____
Hours Worked per week  Dependent Add/Delete Enrollment End dt____/____/____
 Change Name/Address  Late  Hourly  Salary
Salary $______ Required only if Life, STD, or LTD  Waiving Coverage Enrollee
 Termination  Union  Non-Union  Retired
Plan based on salary  Other ____________________________
 Other _________________________

A. Employee Information If you are waiving all coverage, please complete sections A and G.
Last Name First Name MI Social Security Number Home/Cell Phone
Work Phone
Address Apt # City State Zip Code Language preference, if not English

Date of Birth Sex Height Weight Used tobacco in the last Email Address
/ / M F 12 months?  Yes  No
Marital Status Physician* (First & Last Name)/ ID # Primary Care Dentist** (First & Last Name)/ ID #
 Single  Married
 Divorced  Widowed
B. Family Information List All Enrolling (Attach sheet if necessary)
Last Name First Name MI Sex Relationship*** Physician* (Name/ID#) Tobacco
Birthdate Height Weight
Social Security Number Primary Care Dentist** (Name/ID#) Used
M Spouse  Yes
[/Domestic
F Partner]  No

M  Yes
Dependent
F  No

M  Yes
Dependent
F  No

M  Yes
Dependent
F  No

M  Yes
Dependent
F  No

*Important: For UnitedHealthcare Navigate, Select, Select Plus, and other products requiring you to choose a Primary Care Physician, you
must use the UnitedHealthcare directory of providers to choose a Primary Care Physician for yourself and each of your covered dependents.
**Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. ***For court ordered dependent,
legal documentation must be attached. If dependent does not reside with eligible employee, please provide address on a separate sheet.

Coverage Provided by “UnitedHealthcare and Affiliates”:

Medical coverage provided by UnitedHealthcare Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica
Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company

SB.EELNG.10.PA 6/10 450-5152 12/10

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Employee Name __________________________________________________________________________________________________________
Please check the box for each coverage you or your dependents are enrolling in.
C. Product Selection If your employer offers a choice of plans, indicate which plan you are selecting. Indicate the dollar amount
selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term Disability
(STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection.

Person Medical Dental Vision Basic Life/AD&D Supp Life/AD&D

Employee  _____________  _____________   $_____________  $_____________
Spouse [Domestic Partner]  _____________  _____________   $_____________  $_____________
Dependent  _____________  _____________   $_____________  $_____________
Person STD STD Buy Up LTD LTD Buy Up
Employee  $_____________  $_____________  $_____________  $_____________
Life Insurance Beneficiary’s Full Name and Address Relationship

D. Prior Medical Insurance Information This section must be completed to receive credit for prior medical coverage.
Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?
 NO  YES (if yes, please complete this section.)
Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___
Prior coverage type:  Employee  Spouse  Child(ren)  Family
E. Other Medical Coverage Information This section must be completed. (Attach sheet if necessary.)
On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,
including another UnitedHealthcare plan or Medicare?  YES (continue completing this section)  NO (skip the rest of this section)
Name of other carrier ______________________________________________________
Other Group Medical Coverage Information Type Effective Date End Date Name and date of birth of policyholder
(only list those covered by other plan) (B/S/F)* MM/DD/YY MM/DD/YY for other coverage
Employee:
Spouse Name:
Dependent Name:
Dependent Name:
Dependent Name:
*B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)
S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.
F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.
Medicare – Employee Information: If enrolled in Medicare, please attach a copy of your Medicare ID card.
 Enrolled in Part A: Effective Date _____________  Ineligible for Part A*  Not Enrolled in Part A (chose not to enroll)**
 Enrolled in Part B: Effective Date _____________  Ineligible for Part B*  Not Enrolled in Part B (chose not to enroll)**
 Enrolled in Part D: Effective Date _____________  Ineligible for Part D*  Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:  Over 65  Kidney Disease  Disabled  Disabled but actively at work
Are you receiving Social Security Disability Insurance (SSDI)?  YES  NO Start Date ___ /___ /___
Medicare – Spouse/Dependent Name: ____________________________________________
 Enrolled in Part A: Effective Date _____________  Ineligible for Part A*  Not Enrolled in Part A (chose not to enroll)**
 Enrolled in Part B: Effective Date _____________  Ineligible for Part B*  Not Enrolled in Part B (chose not to enroll)**
 Enrolled in Part D: Effective Date _____________  Ineligible for Part D*  Not Enrolled in Part D (chose not to enroll)**
Reason for Medicare eligibility:  Over 65  Kidney Disease  Disabled  Disabled but actively at work
*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.
** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain
coverage under Medicare Part A, Part B, and/or Part D as applicable.

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 F. Medical History
Employee Name ____________________________ SSN _____________________ Group Name __________________________________
Has anyone on this application consulted with or been examined or treated by any health care professional during the last 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
problem and explain fully below. Please note that, if you leave out or misrepresent information, we may terminate or not renew your
coverage, or we may change your premium retroactive to the date your policy became effective. UnitedHealthcare is only seeking to collect
information about the current health status of those persons listed on the application. In answering these questions, you should not include
any genetic information. Please do not include any family medical history information or any information related to genetic services or genetic
diseases for which you believe you or your dependents may be at risk.
1 Cancer  Breast  Colon  Leukemia  Lymphoma  Liver  Lung  Melanoma  Other ___________________
 Yes  No  Testicular  Brain  Ovarian  Cervical  Prostate Stage _____
2 Heart/Circulatory  Aneurysm  Bypass  Angioplasty/Stent  Congestive Heart Failure  Elevated Cholesterol/Triglycerides
 Yes  No  Heart Disease  High Blood Pressure  Stroke  Angina  Hemophilia  Blood Clots  Pacemaker
 Blood Disorder  Sickle Cell Anemia  MI  Other ______________________________________________
3 Reproductive  Current Pregnancy (due date___________ )  Multiples (#___ )  Pregnancy Complications  Fibroids
 Yes  No  Menstrual Disorders  Breast Disorders  Endometriosis  Infertility  Other _______________________
4 Intestinal/Endocrine  Chronic Pancreatitis  Colon Disorder  Crohn’s  Ulcerative Colitis  Diabetes  Cirrhosis  IBS
 Yes  No  Hepatitis B/C  Reflux  Liver Disorder  Ulcer  Growth Hormones  Other_______________________
5 Brain/Nervous  Alzheimer’s Disease  Cerebral Palsy  Migraines  Multiple Sclerosis  Paralysis  Seizures/Epilepsy
 Yes  No  Parkinson’s Disease  Tumor  Head Injury  Cyst  Other ____________________________________
6 Immune  Scleroderma  ALS  Rheumatoid Arthritis  Psoriasis  AIDS  HIV+  Lupus  Immuno Deficiency
 Yes  No  Other ____________________________________________________________________________________
7 Lung/Respiratory  Allergies  Asthma  Cystic Fibrosis  COPD/Emphysema  Sarcoidosis  Lung Disorders
 Yes  No  Tuberculosis  Sleep Apnea  Other __________________________________________________________
8 Eyes/Ears/Nose/Throat  Acoustic Neuroma  Cataracts  Cleft Lip/Palate
 Yes  No  Deviated Septum  Glaucoma  Retinopathy  Other____________________________________________
9 Urinary/Kidney  Chronic Kidney Stones  Kidney Disorders  Bladder Disorders  Polycystic Kidney Disease
 Yes  No  Prostate Disorder  Renal Failure  Dialysis  Other ___________________________________________
10 Bones/Muscles  Osteoarthritis  Bulging/Herniated Disc  Joint injury  Fibromyalgia/CFS  Shoulder Disorder
 Yes  No  Knee Disorder  Spina Bifida  Back Disorder  Neck Disorder  Other ___________________________
11 Behavioral Health  Anxiety/Depression  ADHD  Bipolar/Manic Depression  Schizophrenia  Autism  Eating Disorder
 Yes  No  Suicide Attempt  Inpat ETOH/Drug  Inpat MH Hosp  Other ____________________________________
12 Transplant  Bone Marrow  Organ  Stem Cell  Discussed Possible Future Transplant
 Yes  No  Transplant Complications Year _____  Other __________________________________________________
13 Rare Diseases  Gaucher disease  Fabry disease  Enzyme Deficiency  Metabolic disorder  Phenylketonuria (PKU)
 Yes  No  Marfan Syndrome  Other __________________________________________________
14 Medication  Current Medications Please List Meds__________________________________________________________
 Yes  No  Medications Taken Within The Past Year Please List Meds __________________________________________
15 Other  Abnormal Test Or Physical Results  Condition Not Mentioned Above
 Yes  No  Treatment Or Surgery Discussed Or Advised  Pending Test Results  Inpat Hosp/Surg in Past Yr.
 Pending w/c claim  Tests Advised or Recommended  Refer to Specialist  Disability
Please give details below (If additional space is required, please attach a separate sheet and be sure to date and sign that sheet)

Question # Person Condition/Diagnosis Treatment Current Meds Physician’s Name Dates Treated Prognosis

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 G. Waiver of Coverage Declining coverage due to existence of other coverage: I understand that by waiving coverage at this time, I will
I decline all coverage for:  Spouse’s Employer’s Plan  Individual Plan not be allowed to participate unless I qualify at a special
 Myself  Covered by Medicare  Medicaid enrollment period or as a late enrollee, if applicable, or at
 Spouse  COBRA from Prior Employer  VA Eligibility the next open enrollment period. I also understand that
 Dependent Children  Tri-Care pre-existing limitations may apply as explained in the
 Myself and all dependents  I (we) have no other coverage at this time
Rights and Responsibilities brochure which I have
 Other ____________________________________
received with this form.
Date Employee Signature if waiving coverage

H. Signature I authorize UnitedHealthcare Insurance Company and its affiliates ("UnitedHealthcare and Affiliates") to obtain,
use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I
understand these records may contain information created by other persons or entities (including health care providers) as well as information
regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive
health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical
facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to
UnitedHealthcare and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and
Affiliates to make decisions regarding eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary
and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if
permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in
writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and
Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and
use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months
after the date it is signed.
I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the
indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to
be deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the application. I (we)
understand that UnitedHealthcare and Affiliates is not bound by any statements I (we) have made to any agent or to any other persons, if
those statements are not written or printed on this application and any attachments. I have a continuing obligation to report changes in health
status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my identification card.
Please maintain a copy of this authorization for your records.

Date Employee Signature for all applying Spouse Signature (if applying for coverage)

I. Census Information (optional)

NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with
enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.
1. Race, check all that apply:  White  Black, African-American  American Indian/Alaska Native  Asian
 Native Hawaiian/Pacific Islander  Other Race, please specify_______________________
2. Are you of Hispanic or Latino origin?  Yes  No

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