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Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT 06156 Aetna VisionSM Preferred Enrollment/Change Request Aetna Life Insurance Company TO COMPLY WITH CALIFORNIA LAW WHEREVER THE TERM “SPOUSE” APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC PARTNER. Instructions: Refer to the instructions on the back before completing this form. You 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. Suffix Control Account Plan Number Employer Group Information (To Be Completed by Employer) Employer Name – Full Name of Business or Organization Employer Address (Street, City, State, ZIP Code) – Primary Location of Business or Organization A. Type of Activity – Employee Completes Sections A – D. Change – Check all that apply. Enrollment – Check one. New Enrollee/Subscriber Add Spouse Add Dependent Child Effective Date: Name Change / / Other Date of Hire: Control/Suffix/Acct/Plan: / / Rehire/Reinstatement Date of Rehire/ Reinstatement / / Date of Event: / / Reason: Please Print Clearly. Remove or Terminate – Check all that apply. Remove Spouse Remove Dependent Child Employee Withdrawal/ Termination Cancel Coverage Effective Date: / Reason: / Continuation of Coverage, i.e., COBRA, CalCOBRA Not all options are available. Contact Employer for available options. Employee Dependents Coverage for: Length of Continuation (months): 18 36 Other 29 – Attach disability determination from the Social Security Administration Date of Loss of Coverage: / / / / Date of Qualifying Event: Continuation of Coverage Expiration Date: / / B. Employee Information Social Security Number Last Name, First Name, M.I. Home Address Employee Status Active Retired Subscriber Primary Language (other than English) Primer Idioma del suscriptor (que no sea el Ingles) What is your primary Language? ¿Cuál es su primer idioma? Home Telephone Apt. No. City, State Work Telephone ZIP Code Subscriber Disability Do you have a disability which affects your ability to communicate or read? Yes No If Yes, please indicate the nature of your disability. C. Product Information Aetna VisionSM Preferred Aetna VisionSM Preferred may not be available in all states. D. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Check this box if you are refusing coverage for your dependents. * Provide details for “Yes*” responses below. 1. Employee Name - Last, First, M.I. Relationship (A)dd Code (C)hange Self (R)emove Birthdate (MM/DD/YYYY) Social Security Number Other Vision Coverage Currently Covered Physically or Mentally by Medicare Disabled Yes* / / Yes* N/A 2. Spouse Name - Last, First, M.I. (Explain difference in last name in Special Remarks.) (A)dd (C)hange (R)emove Birthdate (MM/DD/YYYY) Social Security Number (if dependent Other Vision Coverage Currently Covered has no SSN, write “None”) by Medicare Yes* / / Yes* Relationship Code Physically or Mentally Disabled Yes Sex (M/F) Student N/A Sex (M/F) Student Yes Continued on Page 2 GR-68610-6 (1-10) 1 CA R-POD D. Individuals Covered – (continued) List individuals for whom you are enrolling or adding/changing/removing coverage. * Provide details for “Yes*” responses below. Attach sheet to list additional children. 3. Child Name - Last, First, M.I. (Explain difference in last name in Special Remarks.) (A)dd (C)hange (R)emove Birthdate (MM/DD/YYYY) Social Security Number (if dependent Other Vision Coverage Currently Covered has no SSN, write “None”) by Medicare Yes* / / Yes* 4. Child Name - Last, First, M.I. (Explain difference in last name in Special Remarks.) (A)dd (C)hange (R)emove Birthdate (MM/DD/YYYY) Social Security Number (if dependent Other Vision Coverage Currently Covered has no SSN, write “None”) by Medicare Yes* / / Yes* 5. Child Name - Last, First, M.I. (Explain difference in last name in Special Remarks.) (A)dd (C)hange (R)emove Birthdate (MM/DD/YYYY) Social Security Number (if dependent Other Vision Coverage Currently Covered has no SSN, write “None”) by Medicare Yes* / / Yes* 6. Child Name - Last, First, M.I. (Explain difference in last name in Special Remarks.) (A)dd (C)hange (R)emove Birthdate (MM/DD/YYYY) Social Security Number (if dependent Other Vision Coverage Currently Covered has no SSN, write “None”) by Medicare Yes* / / Yes* Relationship Code Physically or Mentally Disabled Yes Relationship Code Physically or Mentally Disabled Yes Relationship Code Physically or Mentally Disabled Yes Relationship Code Physically or Mentally Disabled Yes Sex (M/F) Student Yes Sex (M/F) Student Yes Sex (M/F) Student Yes Sex (M/F) Student Yes 1. If “Yes” to Other Vision Coverage and/or Currently Covered by Medicare above, provide effective dates, name & policy number of insurance carrier, vision plan or other source & your Member Identification Number. 2. Does any dependent listed above live at a different address than the employee? Yes No If “Yes,” who & what address? Special Remarks: GR-68610-6 (1-10) 2 CA Conditions of Enrollment NOTICE: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Applicant Acknowledgments and Agreements On behalf of myself and the dependents listed on Pages 1 and 2, I agree to or with the following: 1. I acknowledge that by enrolling in an Aetna VisionSM Preferred plan, coverage is underwritten by Aetna Life Insurance Company (referred to as “Aetna”) and that certain claims adjudication and other administrative services are provided by First American Administrators, Inc. (an affiliate of EyeMed Vision Care, LLC) and/or its affiliates. 2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage. 3. 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. 4. 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. Misrepresentation Attention California Residents: For your protection, California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Employee Signature By checking this box you agree to use Aetna Navigator®, Aetna’s member self-service website for all future printed materials and understand you may choose to receive paper documents in the future. To the best of my knowledge, 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 Employee Enrollment/Change Request form. Date (Month/Day/Year) Employee E-mail Address (optional) Employee Signature - Required / X / Employer Verification (To Be Completed by Employer) Title Employer Signature - Required X Date (Month/Day/Year) / / Instructions Employer  Complete the Employer Group Information at the top of Page 1.  Complete the Employer Verification below the Employee signature on Page 3 (above). Employer must sign & date the Enrollment/Change Request for new enrollments or coverage changes to be processed. Employee – Complete Sections A – D Additional dependent and/or other information may be provided on a separate sheet. All attachments must be signed and dated. Section A – Type of Activity:  Check box(es) indicating reason(s) for submitting this Enrollment/Change Request.  Provide Effective Date(s) & Date of Event(s) where requested. Section B – Employee Information:  Complete all information in order for your Enrollment/Change Request to be processed. Section C – Product Information Section D – Individuals Covered:  Add/Change/Remove – Use “A”, “C”, or “R” to indicate whether you are adding, changing or removing coverage for an individual.  Print your full name along with the names(s) of your dependent(s), if applicable. Indicate Sex, Birthdate, & Social Security Number for each individual.  Relationship Code – Use ONLY: H=Husband, W=Wife, S=Son, D=Daughter, Y=Sponsored Male, X=Sponsored Female. If the dependent is NOT your spouse or a biological or legally adopted child, please indicate relationship to employee in Special Remarks.  If you or your dependent(s) have Other Vision Coverage and/or are Currently Covered by Medicare, check the “Yes” box(es) and provide beginning & ending effective dates, name & policy number of insurance carrier, vision plan or other source & your Member Identification Number for the insurance plan in the space provided in Number 1.  If a dependent is Physically or Mentally Disabled & financially dependent, check “Yes” & provide proof of disability from the attending physician.  If a dependent is a Student, check “Yes”. Refer to your Summary Coverage for plan definitions. Aetna may request that you provide proof from the educational institution. Conditions of Enrollment/Misrepresentation – Employee Signature: Employee must sign & date the Enrollment/Change Request for new enrollments or coverage changes to be processed. GR-68610-6 (1-10) 3 CA DOI Written Notice of Availability of Language Assistance CDI Notice of Language Assistance-Trad ©2008 Aetna Life Insurance Company GR-68610-6 (1-10) 4 CA