LifeEnrollment/ChangeRequest
Aetna LifeInsuranceCompany
AetnaLifeInsuranceCompany
151FarmingtonAvenue
Hartford,CT06156
Refer to theinstructionsonPage 4 whencompleting thisform.
A.EmployerGroupInformation
B.Employee Information–Please Print all Information
EmployeeSocialSecurityNumber / EmployeeName / EmployeeAnnualEarnings$
EmployeeHomeAddress(Number,Street,Apt. No., City,State,ZIP Code) / Birthdate(MM/DD/YYYY)
// / Sex
Male
Female
TelephoneNumbers
Home()Work() / Occupation/Title / WorkState
C.Declination/WaiverofCoverage- Tobecompleted if coverageisdeclinedorrefusedbyemployee.
I acknowledgeI havebeengiventherighttoapplyfor thiscoverage,however,I amelectingnottoenroll.
D.Enrollment/ChangeInformation
PleasesignhereONLY IFYOU ARE DECLINING coverage.
Employee Signature X Date
1. Enrollment-Checkone.2. Changeappliesto:
EffectiveDate(MM/DD/YYYY)
EffectiveDate(MM/DD/YYYY)
NewEmployee
Rehire/Reinstatement
LateApplicant
Retiree
04/01/2016
Date ofHire/Rehire(MM/DD/YYYY)
Employee
Spouse
Child(ren)
04/01/2016
CheckhereifenrollmentisduetoaFamilyStatuschange. CheckhereifenrollmentisduetoanAnnualEnrollmentperiod.
E. EmployeePlan OptionsandCoverageAmounts
CheckhereifenrollmentisduetoaFamilyStatuschange. CheckhereifenrollmentisduetoanAnnualEnrollmentperiod.
BasedontherequirementsofyourPlan,youmayberequiredtosubmitevidenceofgoodhealth.1. Employee must beenrolledfor employeecoverageinorder to enrollspouse/child(ren)for coverage.
EnrollChangePlanIncrease/Buy-upDecrease
CancelTerminateOtherChanges(Provide details inSectionH, SpecialRemarks.)
2.
OptionalLife
OptionalAD&D
3. BeneficiaryDesignation(LifeInsuranceONLY)SpouseandChild(ren)coverageBeneficiaryisalwaysthe Employee.
Ifadditionalbeneficiaries,useSectionH,SpecialRemarks.* IfnamingmorethanoneBeneficiary,percentagesmust equal 100%.
FullBeneficiaryName
(First,Middle, Last) / SocialSecurityNumber
ofBeneficiary / Relationshipto Employee / % of
Benefit*
Primary
PrimaryContingent
PrimaryContingent
PrimaryContingent
Pleasemakeacopyforyourrecords.Visitus at
F.SpousePlanOptionsandCoverage Amounts–PleasePrintall Information.Checkthisboxifyou arenotelectingspouse coverage.
BasedontherequirementsofyourPlan,yourspousemayberequiredtosubmitevidenceofgoodhealth.1. SpouseName / Relation. Code / Sex
MF / Birthdate(MM/DD/YYYY)
// / SocialSecurityNumber
2. Employee must beenrolledfor employeecoverageinorder to enrollspouseforcoverage.
EnrollChangePlanIncrease/Buy-upDecrease
CancelOtherChanges(Provide details inSectionH, SpecialRemarks.)
3.
BasicDependentLife–SpouseSupplemental/VoluntaryDependentLife–SpouseBasicDependentADD/ADPL–Spouse Supplemental/VoluntaryDependentADD/AD&PL–Spouse
G.ChildPlanOptionsandCoverage Amounts–Please Printall Information.Checkthisboxifyou arenotelectingchild(ren)coverage.
BasedontherequirementsofyourPlan,youmayberequiredtosubmitevidenceofgoodhealthforyourchild(ren).1.Child(ren)Name(First,MiddleInitial, Last)
(ExplaindifferenceinlastnamesinSectionH,Special Remarks.) / Relation. Code / Sex
M F / Birthdate
MMDDYYYY / SocialSecurityNumber
(Ifchildhas noSSN,write“None”) / FullTime
Student
// / Yes
//
//
//
//
2.Employee must beenrolledfor employeecoverageinorder to enrollchild(ren)for coverage.
EnrollChangePlanIncrease/Buy-upDecrease
Cancel– Areotherchild(ren)still coveredunderthisplan?YesNoOtherChanges(Provide details inSectionH, SpecialRemarks.)
3.
OptionalDependentLife–ChildOptionalDependentADD–Child
H.SpecialRemarks- Usethis spaceto provideclarification and/or additional informationforSectionsEthroughG.PleasePrint Clearly.
I.Certification- SignaturesRequiredEmployee’sE-mail Address:
Mysignaturebelowsignifiesmy agreementwiththestatementsandauthorizationintheCertificationandAuthorizationsectionandtheMisrepresentationsectiononPage3ofthisform.
EmployeeSignature(Required)
X / Date / EmployerSignature(Required)
X / Date
CertificationandAuthorization
1. I certifythatallinformationonthisformistrueand completetothebestofmyknowledgeandbelief.I understandthatthis insuranceissubjecttoalloftheterms ofthePlanofInsurancecontainedinthegrouppolicyandsummarizedintheannouncementmaterialsprovidedme andthe certificateissuedtome.
2. I understandthattheeffectivedateof insuranceformyselfor foranyofmydependentsis subjecttomybeingactivelyatworkonthatdateandthattheeffective dateof insuranceforanyofmydependentsisalso subjecttothedependenthealthconditionrequirementsofthePlan.Further,I understandthatanyinsurance subjecttoevidenceofgoodhealthor medicalinformationwillnotbecomeeffectiveuntilAetnagivesitswrittenconsent.
3. I understandthat, intheeventI failto signthisformwithin31daysoftheeffectivedateofeligibilityor thatforanyreasonAetnadoesnotreceivenoticeofthe
Enrollment/ChangeRequestwithinareasonabletimefollowingthedateI waseligibletoenrollor changemycoverage,myandmydependents'eligibilitymaybe affected.
4. I requestmyemployertoarrangefortheissuanceof GroupLifeCoverageforwhichI amor maybecomeeligibleandauthorizedeductionsoftherequired contributionsfrommyearnings.
Misrepresentation
Anypersonwhoknowinglyandwithintenttoinjure,defraudor deceiveanyinsurancecompanyor otherpersonfilesanapplicationfor insuranceor statementof claimcontaininganymateriallyfalseinformationorconceals,forthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulent insuranceact,whichisacrimeand subjectssuchpersontocriminalandcivilpenalties.
AttentionArkansas,Louisiana,RhodeIslandandWestVirginiaResidents:Anypersonwhoknowinglypresentsafalseor fraudulentclaimforpaymentofa lossor benefitorknowinglypresentsfalseinformationinanapplicationfor insuranceisguiltyofacrimeandmaybe subjecttofinesandconfinementinprison. AttentionOhioandPennsylvaniaResidents:Anypersonwhoknowinglyandwith intenttodefraudanyinsurancecompanyor otherpersonfilesanapplication for insuranceorstatementof claimcontaininganymateriallyfalseinformationor conceals,forthepurposeofmisleading,informationconcerninganyfactmaterial theretocommitsafraudulentinsuranceact,whichis a crimeandsubjectssuchpersontocriminaland civilpenalties.
AttentionCaliforniaResidents:For yourprotectionCalifornialawrequiresthefollowingtoappearonthisform.Anypersonwhoknowinglypresentsafalseor fraudulentclaimforpaymentofa lossisguiltyofa crimeandmaybe subjecttofinesand confinementinstateprison.
AttentionColoradoResidents:Itisunlawfultoknowinglyprovidefalse,incomplete,or misleadingfactsor informationtoan insurancecompanyforthepurposeof defraudingor attemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialof insurance,and civildamages.Anyinsurancecompanyor agentofaninsurancecompanywhoknowinglyprovidesfalse,incomplete,or misleadingfactsor informationtoapolicyholderor claimantforthepurposeof defraudingor attemptingtodefraudthepolicyholderor claimantwithregardtoa settlementor awardpayablefrominsuranceproceedsshallbereportedtothe Coloradodivisionofinsurancewithinthedepartmentofregulatoryagencies.
AttentionFloridaResidents:Anypersonwhoknowinglyandwithintentto injure,defraud,or deceiveanyinsurer,filesa statementofclaimor anapplication containinganyfalse,incompleteormisleadinginformationisguiltyofafelonyofthethirddegree.
AttentionKansasResidents:Anypersonwho knowinglyandwith intentto injure,defraudor deceiveanyinsurancecompanyor otherpersonsubmitsan enrollmentformfor insuranceor statementofclaimcontaininganymateriallyfalseinformationor conceals,forthepurposeofmisleading,informationconcerning anyfactmaterialtheretomayhave violatedstatelaw.
AttentionKentuckyResidents:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyor otherpersonfilesanapplicationforinsuranceor statementofclaimcontaininganymateriallyfalseinformationorconceals,forthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsa fraudulentinsuranceact,whichisacrimeandmaysubjectsuchpersonto criminaland civilpenalties.
AttentionMaineandTennesseeResidents:It isa crimetoknowinglyprovidefalse,incompleteor misleadinginformationtoan insurancecompanyforthe purposeofdefraudingthe company.Penaltiesmayincludeimprisonment,finesor denialof insurancebenefits.
AttentionMarylandResidents:Anypersonwho knowinglyandwillfullypresentsafalseor fraudulentclaimforpaymentofa lossor benefitor whoknowinglyand willfullypresentsfalseinformationinanapplicationfor insuranceisguiltyofacrimeandmaybe subjecttofinesandconfinementinprison.
AttentionNewJerseyResidents:Anypersonwhoincludesanyfalseor misleadinginformationonanapplicationforaninsurancepolicyorknowinglyfilesa statementofclaimcontaininganyfalseor misleadinginformationis subjecttocriminaland civilpenalties.
AttentionNewYorkResidents,thefollowingstatementappliesonlyto yourADDandDisabilitycoverage(s):Anypersonwhoknowinglyandwith intentto defraudanyinsurancecompanyorotherpersonfilesan applicationforinsuranceor statementofclaimcontaininganymateriallyfalse information,or concealsfor the purposeofmisleading,informationconcerninganyfactmaterialthereto,commitsafraudulentinsuranceact,whichisacrime,andshallbesubjecttoacivil penaltynottoexceedfive thousanddollarsandthe statedvalueofthe claimforeach violation.
AttentionNorthCarolinaResidents:Anypersonwhoknowinglyandwithintentto injure,defraudor deceiveanyinsurancecompanyor otherpersonfilesan applicationfor insuranceor statementof claimcontaininganymateriallyfalse informationorconceals,forthepurposeofmisleading,informationconcerninganyfact materialtheretocommitsafraudulentinsuranceact,whichmaybe a crimeand subjectssuchpersontocriminalandcivilpenalties.
AttentionOklahomaResidents:WARNING:Anypersonwho knowingly,andwithintenttoinjure,defraudor deceiveanyinsurer,makesanyclaimforthe proceedsofaninsurancepolicycontaininganyfalse,incompleteor misleadinginformationisguiltyofafelony.
AttentionOregonResidents:Anypersonwhowithintentto injure,defraudor deceiveanyinsurancecompanyor otherpersonsubmitsan enrollmentformfor insuranceor statementofclaimcontaininganymateriallyfalse informationor concealsforthepurposeofmisleading,informationconcerninganyfactmaterial theretomayhaveviolatedstate law.
AttentionPuertoRicoResidents:Anypersonwhoknowinglyandwiththeintentiontodefraudincludesfalse informationinanapplicationfor insuranceor file, assist or abet inthefilingofafraudulentclaimtoobtainpaymentofalossor otherbenefit,or filesmorethanoneclaimforthe samelossor damage,commitsafelonyandiffoundguiltyshallbepunishedforeach violationwithafineofnolessthanfivethousanddollars($5,000),nottoexceedten thousanddollars($10,000);orimprisonedforafixedtermofthree(3) years,or both.Ifaggravatingcircumstancesexist,thefixed jailtermmaybe increasedtoamaximumoffive(5) years;andif mitigatingcircumstancesarepresent,thejailtermmaybereducedtoaminimumoftwo(2) years.
AttentionVermontResidents:Anypersonwho knowinglyandwithintentto injure,defraudor deceiveanyinsurancecompanyor otherpersonfilesan application for insuranceorstatementof claimcontaininganymateriallyfalseinformationor conceals,forthepurposeofmisleading,informationconcerninganyfactmaterial theretocommitsafraudulentinsuranceact,whichmaybe a crimeandmaysubjectsuchpersontocriminalandcivilpenalties.
AttentionVirginiaResidents:Anypersonwho knowinglyandwith intentto injure,defraudor deceiveanyinsurancecompanyor otherpersonfilesanapplication for insuranceorstatementof claimcontaininganymateriallyfalseinformationor conceals,forthepurposeofmisleading,informationconcerninganyfactmaterial theretocommitsafraudulentact,whichisacrimeand subjectssuchpersonto criminalandcivilpenalties.
AttentionWashingtonResidents:It isa crimetoknowinglyprovidefalse,incomplete,or misleadinginformationtoan insurancecompanyforthepurposeof defraudingthe company.Penaltiesincludeimprisonment,fines,anddenialofinsurancebenefits.
Instructions
SectionA-EmployerGroupInformation
•Ifnotpreprinted,providethecompleteControl,Suffix,AccountNumberandPlanNumber.
•Ifnotpreprinted,provideEmployernameandaddress.
SectionB–EmployeeInformation
•Completeallinformationrequested.Incompleteor missinginformationmayresultindelaysintheprocessingofyourEnrollment/ChangeRequest.
•Birthdateshouldincludefour-digityearofbirth.
SectionC- DeclinationofCoverage
•IfyouarewaivingcoveragecompleteonlySectionsA,BandC.
•Note:Youremployer’splanmayrequiretheemployeetobeenrolledforemployeecoverageinordertoenrollthespouse/child(ren)forcoverage.If thisrequirementispartofyouremployer’splan,theEnrollment/ChangeRequestformwillstatethisin SectionsE1,F2andG2.
SectionD- Enrollment/ChangeInformation
•CheckallapplicableboxesinSectionD1.
•CompletetheEffectiveDateand DateofHire/Rehire.
•Ifyouaremakingachange,checkallapplicableboxesandcompletetheEffectiveDatein SectionD2.
SectionE-EmployeePlanOptionsandCoverageAmounts
•ChecktheboxapplicabletotheactionyouareinitiatinginSectionE1.
•Checkthebox(es)applicabletothebenefit(s)youwishtoenroll/changeandprovidethecoverageamountyouarerequestingin SectionE2.
•Note:EvidenceofGoodHealthmayberequired.Pleaserefertoyourplandocumentsfordetails.
•Ifapplicable,aTobaccoUse statementwillbeincludedin SectionE2.Thisquestionmustbecompleted.
•CompletetheBeneficiaryDesignationin SectionE3onlyifyouremployer’splanincludesaLifeInsurancebenefitandyouareelectingthisLife
Insurancebenefit.
•Providethefulllegalnameofyourbeneficiary(ies),SocialSecurityNumber,relationshiptotheemployeeandthepercentageofyourbenefitthatwill bepaidtothedesignatedbeneficiary(ies)in theeventofyourdeath.Dollarsandcentsshouldnotbespecified.Whenaddedtogether,thesumof the percentagesgoingtotwoormorenamedbeneficiariesshouldnotbemoreor lessthan100%.Contingentbeneficiary(ies)willonlyreceive proceedsifallprimarybeneficiarieshavepredeceasedtheemployee.
SectionF-SpousePlanOptionsandCoverageAmounts
•Ifenrolling/changingspousecoverage,providethefullnameofyourspouseandallotherinformationrequestedin SectionF1.
•RelationshipCode- Selectone:H=Husband,W=Wife,N=DivorcedSpouse,Y=SponsoredMale,X=SponsoredFemale.
•Birthdateshouldincludefour-digityearofbirth.
•ChecktheboxapplicabletotheactionyouareinitiatinginSectionF2.
•Checkthebox(es)applicabletothespousalbenefit(s)youwishtoenroll/changeandprovidethecoverageamountyouarerequestingin SectionF3.
•Note:EvidenceofGoodHealthmayberequired.Pleaserefertoyourplandocumentsfordetails.
•Ifapplicable,aTobaccoUse statementwillbeincludedin SectionF3.Thisquestionmustbecompletedforyourspouse.
SectionG-ChildPlanOptionsandCoverageAmounts
•Ifenrolling/changingchildcoverage,providethefullname(s)ofyourdependentchild(ren)andallotherinformationrequestedin SectionG1.
•RelationshipCode- Selectone:S=Son,D=Daughter.Ifthedependentchild(ren)isnotyourbiologicalor legallyadoptedchild,pleaseindicate relationshiptoemployeeinSectionH,SpecialRemarks.
•Birthdateshouldincludefour-digityearofbirth.
•Ifadependentchild(ren)isafulltimestudent,besuretocheck “Yes.”Refertoyourplandocumentsforplandefinition.
•ChecktheboxapplicabletotheactionyouareinitiatinginSectionG2.
•Checkthebox(es)applicabletothechildbenefit(s)youwishtoenroll/changeandprovidethecoverageamountyouarerequestingin SectionG3.
•Note:EvidenceofGoodHealthmayberequired.Pleaserefertoyourplandocumentsfordetails.
SectionH- SpecialRemarks
•Usethisspacetoprovideclarificationand/oradditionalinformationifneeded.
•Pleasenote:AdditionalinformationprovidedbyAetnaor youremployermayappearinthisspace.
SectionI-Certification(SignatureRequired)
•ReadtheCertificationandAuthorizationsectionandtheMisrepresentationsectiononPage3priortosigningtheform.
•Signanddatetheform.
•Pleasemakeacopyofthisformforyourrecords.