NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your
health information by taping or stapling the form so that pages 2 and 3 are not visible.
North Carolina Small Group Business (50 or Fewer Eligible Employees)
Employee Enrollment/Change Form
Group Number
Life, Accidental Death & Dismemberment, Disability, Aetna Managed Choice plans, and the Aetna PPO plans are underwritten by
Aetna Life Insurance Company. Aetna Choice POS plans and Aetna HMO plans are underwritten by Aetna Health Inc. Dental plans
are provided or administered by Aetna Life Insurance Company.
Company Name
Member Aetna ID Number (if available)
INSTRUCTIONS: You, the employee, must complete this application in full or it will be returned to you resulting in a
delay in processing. You are solely responsible for its accuracy and completeness. If waiving coverage, please
complete Sections B and H.
Effective Date
New Hire
Rehire/Reinstatement
New Group Enrollment
Late Enrollment
Other
Date of Hire
Change of coverage
Add Spouse/Dependent Child
Name Change
Other
COBRA/State Continuation for:
Employee
Dependent
Length of Continuation:
18
36
Other
Original Qualifying Event Date
Employee Termination
Remove Spouse/
Dependent Child
Cancel Coverage
A. Coverage Selection – Please print clearly, using black ink.
Control/Group No.
Suffix
Account
Qualifying Event
Plan No. Class Code Control/Group No.
1. Medical - Check one.
Suffix
Account
Plan No.
Control/Group No.
Suffix
2. Dental - Check one.
Standard Plans
Voluntary Plans
Option 1 - Schedule
Option V1 – PPO 1000
Option 2 – PPO 1000
Out-of-State PPO Max
Option 3 - PPO 15000
Option 4 – DentalFund/PPO Max
Out-of-State PPO Max
Aetna HMO (Open Access) –
Plan Option
Aetna Managed Choice® (Open Access) –
Plan Option
Beneficiary Social Security No.
Plan No.
3. Life and Disability
Basic Life/AD&D Ultra®
Optional Dependent Life
Short Term Disability
Life & Disability Packaged Plan
Before today, were you covered under this employer’s
Yes
No
dental plan?
Aetna Choice® POS (Open Access) –
Plan Option
Account
Beneficiary Designation - Full Name (First, Middle, Last)
Relationship to Employee
B. Employee Information - Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Address
Apt. No.
Work Address
City, State
Salary (required)
No. of Hours
Worked Per
Week
Home Telephone
$
Hourly
Weekly
Monthly
Primary Language Spoken
(Optional)
City, State
ZIP Code
ZIP Code
Check One
Full-Time
Part-Time
1099
Retired
Work Telephone
Seasonal
Temporary
No. of Dependents Including
Spouse
C. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
NOTE FOR MEDICAL AND DENTAL COVERAGE: While the Federal Patient Protection and Affordable Care Act mandates coverage of dependent children up to age 26,
your plan may allow coverage beyond age 26. Some exceptions apply. Please refer to your plan documents or contact your benefits administrator.
Sex
M/F
Name (Last, First, M.I.)
Social Security Number
Birthdate
(MM/DD/YYYY)
Relationship
Employee
Status
Single
Divorced
Married
Widowed
Legally Separated
Different Last Name
1.
Spouse
2.
Child
Child
Stepchild
Other
3.
Child
Child
Stepchild
Other
4.
Different Last Name
Lives at another address
Full-Time Student - Life only
Disabled
Different Last Name
Lives at another address
Full-Time Student - Life only
Disabled
Coverage
Election
PCP Provider
ID Number
Medical
Dental
Life/Dis
Medical
Dental
Life
Medical
Dental
Life
Medical
Dental
Life
D. Dependent Information
List any dependent in Section C living Name:
at another address.
If any dependent’s last name differs Name:
from yours, explain.
Address:
Reason:
Reason:
FOR DEPENDENT LIFE: If age 19 and older and a full-time student, provide the following:
Child Name
E. Race/Ethnicity – Optional
Employee
1.
Spouse
2.
School Name
Number of Credit Hours
(This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)
White – 01
African American or Black – 02
Hispanic or Latino – 03
Asian – 04
Other – 05
White – 01
African American or Black – 02
Hispanic or Latino – 03
Asian – 04
Other – 05
GR-67834-32 (10-10)
Expected Graduation Date
Child
3.
Child
4.
1
White – 01
African American or Black – 02
Hispanic or Latino – 03
Asian – 04
Other – 05
White – 01
African American or Black – 02
Hispanic or Latino – 03
Asian – 04
Other – 05
NC - SGB RRD E
F. Other Insurance
Does anyone age 19 and over enrolling on this enrollment form have current or prior coverage?
Proof of coverage should accompany this enrollment form for pre-existing condition credit
and if an employee is waiving coverage. Acceptable forms of proof are:
1. Certificate of Creditable Coverage from prior carrier, or
2. Copy of ID card or most recent payroll stub showing medical coverage deduction, or
3. Copy of most recent medical premium bill from prior carrier.
Name of Covered Individual
Carrier Name
Yes
No
Failure to provide Proof of Prior Coverage may subject you or a family member
(age 19 and over) to the full pre-existing conditions limitation with no credit for
prior coverage. You may request a Certificate of Creditable Coverage from your
prior carrier. NOTE: If your Plan contains a pre-existing conditions provision,
the pre-existing conditions exclusion and limitation will not apply to a person
under 19 years of age.
Group Number
Start Date
Termination Date
Health
Yes
No
Yes
No
Yes
No
G. Medicare Information
Name of Person
Medicare Part A
Medicare Part B
Medicare Part D
Over Age 65
End-Stage Renal
Disease Eff Date
Disability
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
H. Declination/Waiver of Coverage - Check all that apply.
I understand I am eligible to apply for this coverage through my employer; however, I am waiving coverage as noted below.
Medical for:
Myself
Spouse
Child(ren)
Dental for:
Myself
Spouse
Child(ren)
Life for:
Myself
Spouse
Child(ren)
Disability for:
Myself
Reason for declining coverage (If applicable attach front/back of your health ID card.)
Spousal group coverage
COBRA coverage
Medicare
Military coverage
Medicaid
Another group plan provided by my employer
Individual coverage
Do not want
Retiree coverage
Other:
If declining due to other coverage provide other carrier name:
I certify I have been given the right to apply for this coverage; however, I am waiving coverage as noted above. By declining this group
coverage I acknowledge that myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for
group coverage. Pre-existing conditions, when enrolled in this plan, may not be covered for twelve months. The pre-existing condition
limitation does not apply to pregnancy or to a newborn, an adopted child under age 19, a foster child or a child placed for adoption
under age 19, if the child becomes covered under Creditable Coverage within 31 days of birth, adoption, or placement of adoption. In
addition, the pre-existing condition limitation does not apply to newborns, adopted children, or foster children if no additional Premium
is required under the Certificate of Coverage. NOTE: If your Plan contains a pre-existing conditions provision, the pre-existing
conditions exclusion and limitation does not apply to a person under 19 years of age.
Date (Month/Day/Year)
Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).
X Employee Signature
I. Health Questionnaire for Groups with 1 – 25 Eligible Employees (or 2 - 50 if enrolling for life above the Guarantee Issue amount). All new
business groups do not need to complete this section if they are eligible to complete the Group Medical Questionnaire.
Health History for Employees and your Dependents. The following information is confidential and will not be seen by or given to your employer.
ALL of the questions must be answered by you or your dependents or the enrollment form will be returned.
Incomplete enrollment forms may delay the effective date of your coverage.
1.
Yes
No
Has any person listed on this enrollment form been tested positive for exposure to the Human Immunodeficiency Virus (HIV)
infection or been diagnosed as having AIDS-Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS) caused
by the Human Immunodeficiency Virus (HIV) infection or other sickness or condition derived from such infection?
Check applicable boxes:
Is any female currently pregnant? If so, provide due date
C section planned
Multiple Births Expected (#
)
Complications:
Past or
Present
Yes
No
Yes
No
Has anyone applying for coverage incurred medical expenses in excess of $5,000 in the past 24 months?
Has anyone applying for coverage been prescribed medications in the past 12 months?
Yes
No
Yes
No
Does anyone applying for coverage have a known condition that requires on-going treatment?
Do you or your spouse use tobacco products? If so, check the applicable boxes:
Yes
No
Yes
No
Within the last 5 years has anyone applying for coverage consulted, received treatment, by a doctor, psychiatrist, psychologist, or
other practitioner or been diagnosed with any of the following conditions or disorders? (Check all that apply.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
2.
3.
4.
5.
6.
7.
Diabetes
Infertility
Endocrine/Metabolic
Pancreas
Liver/Hepatitis
Immune System
Blood Disorder
Epilepsy/Seizure
Heart
Paralysis/Paresis
Employee:
Spouse:
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
Cigarettes
Cigarettes
Tumor/Cyst/Growth
Systemic or Discoid Lupus
Lung or Respiratory
Alcohol or Drug Use
Kidney/Bladder/Urinary
Circulatory/Vascular
Digestive/Stomach/Intestinal
Central Nervous System
Pituitary/Adrenal/Growth Disorder
Birth Defects/Congenital Abnormalities
Pipe
Pipe
Cigars
Cigars
u.
v.
w.
x.
y.
z.
aa.
bb.
Arthritis/Bone/Joint/Muscle/Prosthetic Device
Mental/Nervous/Emotional/Eating Disorder
Stroke/Brain/Neurological
Transplant:
Recommended
Pending
Complete
Advised to have surgery or course of treatment not yet determined
Cancer: Type:
Stage
Surgery
Chemo
Radiation
Using:
Crutches
Walker
Wheelchair
Other
Chewing Tobacco
Chewing Tobacco
IF YOU ANSWERED “YES” TO ANY OF THE QUESTIONS IN SECTION I, YOU MUST COMPLETE SECTIONS J and K.
2
GR-67834-32 (10-10)
NC
J. Health Questionnaire – Details for “Yes” Responses in Section I.
Currently Taking
Prescription
Medication(s)
List all individuals enrolling for coverage.
Height
Name
Weight
Smoker
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
K. Provide details below to any boxes checked above. (If additional space is needed, attach a separate sheet and be sure to sign and date the sheet.)
Ques.
No.
Name of Individual
Date of
Onset
Condition/Diagnosis
Date Treatment
Ended
Names of Prescription
Medication
Dosage
Still Taking
Medication
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
North Carolina Contraceptives: If the health benefit plan elected is provided through a “religious employer” (as defined in North
Carolina law) and includes coverage for prescription drugs or devices, the plan may exclude coverage for prescription contraceptive
drugs or devices at the request of the “religious employer”. This is in accordance with North Carolina law § 58-3-178.
Conditions of Enrollment
On behalf of myself and the dependents listed on the reverse side, I agree to or with the following:
1. I acknowledge that by enrolling in the following plans, coverage is provided by the following entities (collectively referred to
as “Aetna”):
● Aetna Choice® POS plans and Aetna HMO plans: Aetna Health Inc.
● Aetna Managed Choice® Open Access plans: Aetna Life Insurance Company
● Life, Accidental Death & Dismemberment, disability, dental and other health coverages: Aetna Life Insurance Company.
2. I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and
until both the eligible employee enrollment form and the employer applications have been accepted and approved by Aetna.
For life and disability coverages: I understand that the effective date of insurance for myself or for any of my dependents
is subject to my being actively at work on that date and that the effective date of insurance for any of my dependents is also
subject to the dependent health condition requirements of the benefit plan. Further, I understand that any insurance s will
not become effective until approved by Aetna. For Dependent Life, dependents are eligible from 14 days of age up to their
19th birthday, or up to their 23rd birthday, if a full-time student.
Continued on next page
GR-67834-32 (10-10)
3
NC
Conditions of Enrollment (continued)
3. I understand and agree that this Enrollment/Change Form may be transmitted to Aetna or its agent by my employer or its
agent. I authorize any physician, other healthcare professional, hospital or any other healthcare organization (“Providers”),
including pharmacies or pharmacy database benefit managers to give to Aetna or its agent information concerning the
medical history, prescription utilization history, services or treatment provided to anyone listed on this Enrollment/Change
Form, including those involving mental health and substance abuse. I further authorize Aetna to use such information and
to disclose such information to affiliates, Providers, payors, other insurers, third party administrators, vendors, consultants
and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation
of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my spouse and
competent adult dependents, and I have obtained their consent to those terms. This authorization will remain valid for 30
months. I understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid
as the original.
4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict
with any benefits comparison, summary or other description of the plan.
5. I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are
independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of
Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to
change. Notice of the change shall be provided in accordance with applicable state law.
6. I understand and agree that, with certain exceptions described in the plan documents, HMO and DMO plans only provide
coverage for referred benefits, and that, in order to be covered, services must be performed either by a participating primary
care physician, primary care dentist, or by the participating specialist, hospital, pharmacy, dentist, or other provider as
authorized by a referral from a participating primary care physician.
7. I understand and agree that, as described in the plan documents, when enrolled for medical coverage, any pre-existing
conditions for my spouse, dependents or myself may not be covered for 12 months. NOTE: If your Plan contains a preexisting conditions provision, the pre-existing conditions exclusion and limitation does not apply to a person under 19 years
of age.
I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment
and Misrepresentation on this Small Group Business (50 or Fewer Eligible Employees) Employee Enrollment/Change Form.
I understand that, in the event I fail to sign this form within 31 days after the above transaction request or for any reason Aetna
does not receive notice of the above transaction request within a reasonable time following the event, my and my dependents’
eligibility may be affected.
I am employed by the employer shown on Page 1, and I am working full time at least 30 hours per week for this employer at the
regular place of business.
Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a
crime and subjects such person to criminal and civil penalties.
Employee Signature
Employee E-mail Address (optional)
Date (Month/Day/Year)
X
Corporate Headquarters
Aetna Health Inc.
1302 Concourse Drive Suite 402
Linthicum, MD 21090
GR-67834-32 (10-10)
Aetna Life Insurance Company
151 Farmington Avenue
Hartford, CT 06156
4
NC
