Broker of Record

Email Contact

M E M B E R T R A N S M I S S I O N C-1 3 7 Effective Date

Universal Event File Carrier Name

Enrollment Reason

G R O U P D E TA I L S P E R S O N A L D E TA I L S

Mahesh V GroupID
Employer Group ID First Name Last Name

Company Administrator Name Title SSN Birth Date

Email Enrolling Dependents Legal Gender

Yes No Female Male

Street Address

Marital Status
City County Single Married Divorced Widowed

State Zip Code

Disabled
Yes No

Group Administrator Signature Signature Date

Street Address

E M P LOY M E N T I N F O R M AT I O N
City County

COBRA
Date Hired / Full-Time State Zip Code Telephone

Title Class & Department Code Division Code Email

Previous Coverage
Hours Worked per Week hourly (H) | salary (S) Annual Salary
Yes / Carrier Name No

Employee Signature Signature Date

G R O U P D E TA I L S

Basic Life Coverage with AD&D Beneficiaries

Basic-Life Policy Amount Name Relationship Date of Birth Percentage

Spouse Basic-Life Policy Amount Name Relationship Date of Birth Percentage

Any Child Basic-Life Policy Amount Name Relationship Date of Birth Percentage

Name Relationship Date of Birth Percentage

VO LU N TA R Y L I F E /A D& D C OV E R AG E S

Employee Spouse Dependent/Child

is not smoker is smoker is not smoker is smoker is not smoker is smoker

Add Employee Voluntary Life Add Spouse Voluntary Life Add Dependent/Child Voluntary Life

Amount
Amount
Amount
I do not want Voluntary Life Coverage I do not want Voluntary Life Coverage I do not want Voluntary Life Coverage

Add Employee Voluntary AD&D Add Spouse Voluntary AD&D Add Dependent/Child Voluntary AD&D

Amount
Amount
Amount
I do not want Voluntary AD&D Coverage

BA S I C & VO L U N TA R Y S T D & LT D

Basic Short-term Disability (STD) Voluntary STD Voluntary LTD

Amount
Amount
Amount
I do not want Voluntary STD Coverage I do not want Voluntary LTD Coverage

Basic Long-term Disability (LTD)

Amount
E M P LOY E E E N R O L L M E N T S

Medical Dental High Low Vision High Low

Plan Name Plan Code Plan Name DHMO Number Plan Name

I do not want Medical Coverage I do not want Dental Coverage I do not want Vision Coverage

Is Employee Current Medical Patient?

Employee Medical PCP NPI number Yes No

D E P E N D E N T E N R O L L M E N T S/C H A N G E S

Add (+) Remove (-)

Spouse Name Relationship SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 1 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 2 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 3 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 4 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 5 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No
E X T R A E N R O L L I N G C H I L D D E P E N D E N T S PAG E (C H I L D 6–11 )

Add (+) Remove (-)

Child 6 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 7 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 8 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 9 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 10 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No

Add (+) Remove (-)

Child 11 Name SSN Date of Birth Sex
Medical Dental Vision Medical Dental Vision
Current Patient? Yes No
Medical PCP NPI number Dental DHMO / Facility Number
Disabled? Yes No