CIGNA International Enrollment and Change Form

CIGNA International Enrollment and Change Form

Section A. - About You
Policy Number: 02018A-001 / Employer Name: Gemini Observatory / Date of change:
Last Name: / First Name: / Middle Name:
Gender:--MaleFemale / Marital Status: / Birth Date: / SS#/Employer ID#:
Country of assignment: / Country of citizenship:
Current International Assignment Information (if necessary, please use the reverse side for additional addresses)
Address: / Street: / Home phone number:
Work phone number:
City: / State/Province: / Facsimile number:
Postal/ZIP code: / Country: / E-mail address:
Section B. - About Your Medical/Vision and Dental Coverage
Type of Change: / New enrollment Add/Remove/Change Dependent Add/End/Change coverage(s)
End all coverages Address change Other:
Medical Elections: / Employee Spouse Children
Dental Elections: / Employee Spouse Children
Section C. – About Your Dependents
Name / Relationship / Birth Date / Gender / Full-time student? / Country of Residence
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
--MaleFemale / --Yes*No
*Please submit proof of full-time student status if dependent child is age 19 or over.

**I hereby certify that the foregoing information is true and correct to the best of my knowledge and accept the provisions on the reverse side of this form. **

Employee name/signature: / Date:
Section D. - Additional Addresses
Address / Who is located at this address?
What should CIGNA International use this address for?
Street: / Home phone number:
Work phone number:
City: / State/Province: / Facsimile number:
Postal/ZIP code: / Country: / E-mail address:
Address / Who is located at this address?
What should CIGNA International use this address for?
Street: / Home phone number:
Work phone number:
City: / State/Province: / Facsimile number:
Postal/ZIP code: / Country: / E-mail address:
Section E. - Provisions

** I accept the insurance provided by my employer’s group insurance plan and authorize deductions from my earnings of the required contributions, if any, toward the cost of the insurance. This authorization applies only if employee contributions are required. **

Section F. - Instructions

Type of Change – please check off the appropriate change and complete the following sections:

• New enrollment: complete sections A, B, C, D (if applicable)
• Add/Remove/Change Dependent: complete sections A, B, C, and D (if applicable)
• Add/End/Change coverage(s): complete sections A, B, and C
• End all coverage(s): complete section A and B (top section only)
• Address change: complete section A, B, and D (if applicable)

Full-time student? Please submit proof of full-time status if dependent child is age 19 or over.

Country of ResidencePlease list the country where each dependent lives. This information helps CIGNA International provide better customer service to you and your dependents.

Additional AddressesPlease list any other addresses, who is at that address, and how CIGNA International should use that address (for example: claim payments)

Send Form to:E-mail and/or Fax completed enrollment form to:

Enrollment Questions? Contact Benefits:
Jeracah Holland / Evelyn Cortes
Human Resources Department
Phone: (808) 974-2503 or 205-644 / Claims/Service Questions? Contact CIGNA International at:
Phone:(800) 441-2668 toll-free (via AT&T Direct Access)
(302) 797-3100 (outside the U.S.A, collect calls accepted)
Fax:(302) 797-3150
(800) 243-6998 toll-free (via AT&T Direct Access)
E-mail: