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SB.EE.07.OR 10/07 600-2378 6/08
To speed the enrollment process, please be
thorough and fill out all sections that apply.
Group Name
Requested Effective Date of Coverage/Date of Change / /
Date of Hire / /
Position/Title
Hours Worked per week
Salary $______
Required only if Life Plan based on salary
Last Name First Name MI Social Security Number Home Phone
Work Phone
Address Apt # City State Zip Code Email Address
Date of Birth Sex Language preference, if not English
/ /
M F
Marital Status
Physician* (First & Last Name)/ ID # Primary Care Dentist (First & Last Name)/ ID #
Single Married
Divorced Widowed
Group Name/Number
To Be Completed by Employer
Reason for Application
New Group Plan New Hire
Life Event/Date_______ Annual
Status Change_______ Open
Dependent Add/Delete Enrollment
Change Name/Address Late
Other ______________ Enrollee
Employee Type
(Check all that apply)
Active
COBRA/State Continuation
Start dt __/__/__ End dt__/__/__
Hourly Salary Other _______
Union Non-Union Retired
A. Employee Information
List All Enrolling (Attach sheet if necessary)
Last Name First Name MI
Sex
Relationship**
Birthdate
Full Time Physician* (Name/ID#)
Social Security Number
Student
Primary Care Dentist (Name/ID#)
Spouse
Dependent
Dependent
Dependent
*IMPORTANT: Please use the UnitedHealthcare directory of providers to choose a Primary Physician (Primary Care) for yourself and each of
your covered dependents, for UnitedHealthcare Select, Select Plus, and other products requiring a Primary Physician designation only. **For
court ordered dependent, legal documentation must be attached. Please see employer representative for more information about the
qualifications for full-time student status. If dependent does not reside with eligible employee, please provide address on a separate sheet.
All references to Spouse include a Domestic Partner.
B. Family Information
M
F
M
F
M
F
M
F
Yes
No
Yes
No
Yes
No
Employee Enrollment Form
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by United HealthCare Insurance Company
Dental coverage provided by United HealthCare Insurance Company, Unimerica Insurance Company, PacifiCare Life Assurance Company.
Life Insurance coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
Vision coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company
(DO NOT STAPLE)
Please check all that apply. Benefit offerings are dependent upon employer selection.
Dual Option Plan Selected
Person Medical Dental Vision Life/Amount Sup Life Sup AD&D STD LTD Medical Dental
Employee $______
Spouse
Dependents
Life Insurance Beneficiary’s Full Name and Address
Relationship
C. Product Selection
MASTERY LEARNING INSTITUTE (ARTHUR ACADEMY)
*
*
Select "Fill a Copy"
Login using your email
Complete Form and select "Finalize"