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 pages 2 and 3 are not visible.
Kansas/Missouri Small Group Business (2 - 50 Eligible Employees)
Employee Enrollment/Change Form
Social Security Number
Employer Name
INSTRUCTIONS: You, the employee, must complete this enrollment form 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 F.
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
A. Coverage Selection - Please print clearly, using black ink.
Control/Group No.
Suffix
Account
Plan No.
Class Code
Remove Spouse/Dependent
Child
Cancel Coverage
Original Qualifying Event Date
(Shaded sections for Employer/Aetna Use Only)
Control/Group No.
Suffix
Account
Plan No.
Reason
Control/Group No.
2. Dental - Check one.
1. Medical - Check one.
COBRA/State Continuation for:
Employee
Dependent
Length of Continuation:
18
36
Other
Employee Termination
Suffix
Account
Plan No.
3. Life and Disability
Standard Plans
Basic Life/AD&D UltraTM
Option 1: DMO
Optional Dependent Life
Option 2: Freedom-of-Choice:
DMO or
PPO
Short Term Disability
Option 3: PPO Max
Life & Disability Packaged Plan
Option 4: Freedom-of-Choice:
DMO or
PPO
Beneficiary Designation - Full Name (First, Middle, Last)
Option 5: PPO 1500
Option 6: PPO 2000
Out-of-State PPO
Beneficiary Social Security Number
Voluntary Plans
Option 1: DMO
Relationship to Employee
Option 2: Freedom-of-Choice:
DMO or
PPO
Option 3: PPO Max
Out-of-State PPO
Before today, were you covered under this employer’s dental plan?
Yes
No
Aetna Managed Choice® POS Open Access:
Plan Option
Aetna Open Choice® PPO:
Plan Option
Aetna Indemnity:
Plan Option
Other:
B. Employee Information - Must be completed by the employee.
Member Aetna ID Number (if available) Last Name, First Name, M.I.
Job Title
Apt. No.
Home Address
Work Address
Home Telephone
City, State
ZIP Code
City, State
Hourly
Monthly
Weekly
ZIP Code
No. of Hours Worked Check One
per Week (no less
than 30 hours)
Salary (required)
$
Primary Language Spoken (Optional)
Work Telephone
No. of Dependents Including Spouse
Full-time
Retired
1099
C. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
Name (Last, First, M.I.)
Sex
M/F
Social Security Number
Relationship
Birthdate
MM / DD / YYYY
Height Weight
(ft, in) (lbs)
Employee
Coverage
Election
Status
Single
Divorced
Married
Widowed
Legally Separated
Medical
Dental
Life/Dis
Spouse
Other
Different last name *
Medical
Dental
Life
Child
Stepchild
Other
Different last name *
Lives at another address *
Disabled (+19)
Medical
Dental
Life
Child
Stepchild
Other
Different last name *
Lives at another address *
Disabled (+19)
Medical
Dental
Life
1.
Spouse
2.
Child
3.
Child
4.
PCP Provider
ID#
* List first name(s) and reason for different last name and/or another address, if applicable:
D. Medicare Information
Name of Person
Medicare Part A
Yes
GR-67834-33 (9-07)
No
Medicare Part B
Yes
Medicare Part D
No
Yes
1
No
Over Age 65
Yes
No
Disability
Yes
End-Stage Renal
Disease Eff Date
No
KS/MO - SGB
R-POD D
E. Other Insurance
Does anyone enrolling on this enrollment form have current or prior medical and/or dental coverage?
Yes
Carrier Name
Name of Covered Individual
No
Failure to provide Proof of Prior Coverage may subject you or
a family member 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.
Proof of coverage must 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.
Group Number
Start Date
Termination Date
Health
Yes
No
Yes
No
Yes
No
Yes
No
F. Declination/Waiver of Coverage - To be completed if medical and or dental coverage is declined or refused by an eligible and/or their eligible family members.
I understand I am eligible to apply for this coverage through my employer; however, I am waiving coverage as noted below. Check all that apply.
Dental
Life
Disability Reason for declining coverage (If applicable attach front/back of your health ID card.):
Employee
Medical
Covered by spouse’s group coverage - Carrier Name and ID number:
Spouse
Medical
Dental
Child(ren)
Medical
Dental
Enrolled in other insurance (check applicable box):
Military
Individual
Retiree
Carrier Name and ID number:
Spouse covered by employer's group insurance
Life
Life
Medicare
Other
TRICARE
CHAMPVA
Do Not Want
I represent I have been given the right to apply for this coverage, however, I am electing not to enroll. 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 medical plan, may not be covered for ninety days.
Please sign here ONLY if you are declining coverage for yourself or dependent(s).
X
Date (Month/Day/Year)
Employee Signature
G. Race/Ethnicity - Optional (This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)
Employee
1.
Spouse
2.
White - 01
African American or Black - 02
Asian - 04
Hispanic or Latino - 03
White - 01
African American or Black - 02
Hispanic or Latino - 03
Asian - 04
Child
Other - 05
3.
Child
Other - 05
4.
White - 01
African American or Black - 02
Asian - 04
Hispanic or Latino - 03
Other - 05
White - 01
African American or Black - 02
Hispanic or Latino - 03
Asian - 04
Other - 05
2-9
H. Health Questionnaire for Groups Enrolling
Eligible Employees
Health History for Individuals and Their 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 and your dependents or the enrollment form will be returned.
• Incomplete enrollment forms may delay the effective date of your coverage.
In the past five (5) years, has any person listed on the enrollment form seen a health care provider(s), had treatment recommended, received
treatment, including prescription medications or been hospitalized for any of the following conditions listed below?
1. Heart attack, heart murmur, stroke, chest pain, high blood pressure, anemia, varicose veins or other disorders of the heart, blood, blood
vessels or high cholesterol? . .......................................................................................................................................................................
2. Ulcer, colitis, gallstones or any other disorder of the stomach, intestines, rectum, pancreas, liver or Hepatitis B/C?..................................
.
3. Cancer, cyst or tumor?..................................................................................................................................................................................
If cancer, please indicate what stage (if known).
4. Disorders of the kidneys, adrenal glands, thyroid gland, urinary system, male or female organs, infertility, menstrual dysfunction or
sexually-transmitted disease (except AIDS/ARC)?.......................................................................................................................................
5. Asthma, emphysema, tuberculosis or any other disorders of the lungs or respiratory system?...................................................................
6. Migraines, fainting spells, epilepsy, mental or nervous conditions, depression, paralysis or any disorder of the brain or nervous system?
If epileptic, date of last seizure:
/
/
(month/day/year)
7. Lupus, arthritis, back trouble or any other disorder of the joints, muscles or bones, including prosthetic device or implants?.....................
8. Any physical deformity, defect or congenital problem?.................................................................................................................................
.
9. Has any person to be covered been positively diagnosed or treated for an immune disorder, AIDS, or AIDS-Related Complex?..............
10. Has any person been treated for alcoholism, other drug or substance abuse, including use of any illegal or controlled drugs, or been
advised to seek treatment for the same?......................................................................................................................................................
11. Has any person been diagnosed with diabetes? If Yes, list date of diagnosis:
/
/
(month/day/year) . ...........................
Insulin dependent
Non-insulin dependent
12. a. Is any female to be covered currently pregnant? If Yes, list due date:
/
/
(month/day/year) ....................................
b. Have there been any complications thus far? .........................................................................................................................................
c. Are multiple births expected? . ................................................................................................................................................................
d. If you are a male listed on this enrollment form, are you expecting a child with anyone, even if the mother is not listed on this enrollment form?...............................................................................................................................................................................................
Yes
No
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE, YOU MUST COMPLETE SECTION J ON PAGE 3.
GR-67834-33 (9-07)
2
KS/MO - SGB
H. Health Questionnaire for Groups Enrolling
2 - 9 Eligible Employees (continued)
Yes
No
13. Has any applicant taken any prescribed medications in the past 12 months? If Yes, list below.................................................................
14. Within the past five (5) years, has any applicant had an abnormal physical exam or been advised to undergo further testing, surgery or
treatment?.....................................................................................................................................................................................................
15. Within the past five (5) years, has any applicant been a patient in a hospital, clinic, surgical center, sanatorium or medical facility as an
outpatient or inpatient (excluding childbirth)?...............................................................................................................................................
.
16. Does anyone named on this enrollment form use tobacco products, including cigarettes, pipe, cigars, or chewing tobacco?....................
If Yes, check applicable boxes:
Employee
Spouse
17. Within the past five (5) years, has any applicant been diagnosed and/or treated for any medical condition or symptom not listed on this
enrollment form? ..........................................................................................................................................................................................
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE, YOU MUST COMPLETE SECTION J BELOW.
10 - 50
I. Health Questionnaire for Groups Enrolling
Eligible Employees
Health History for Individuals and Their 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 and your dependents or the enrollment form will be returned.
• Incomplete enrollment forms may delay the effective date of your coverage.
1. Within the last 24 months 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, disorders or diseases? (Check all that apply.) . ...................
If a condition is not noted, please list it below in Section J.
Diabetes
Paralysis/Paresis
Pituitary/Adrenal/Growth Disorder
Infertility
Tumor/Cyst/Growth
Arthritis/Bone/Joint/Muscle/Prosthetic Device
Endocrine
Systemic or Lupus
Mental/Nervous/Emotional/Eating
Pancreas
Lung or Respiratory
Stroke/Brain/Neurological/Central Nervous System
Liver/Hepatitis
Alcohol or Drug Use
Transplant (recommended, pending or complete)
Immune System
Kidney/Bladder/Urinary
Advised to have surgery or treatment is needed or pending
Cancer or Blood
Heart/Circulatory/Vascular
Had medical claims in excess of $5,000
Epilepsy/Seizure
Digestive/Stomach/Intestinal
Currently pregnant – due date:
/
/
(month/day/year)
Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC) or tested positive for HIV
2. Has anyone applying for coverage been prescribed medications in the past 12 months? .......................................................................
3. Within the past five (5) years, does anyone applying for coverage have a known condition that requires on-going treatment? . .............
4. Do you or your spouse use tobacco products, including cigarettes, pipe, cigars, or chewing tobacco?....................................................
If Yes, check applicable boxes:
Employee
Spouse
Yes
No
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE, YOU MUST COMPLETE SECTION J BELOW.
J. Health Questionnaire - Details for "Yes" Responses in Sections H or I.
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS IN SECTIONS H or I, YOU MUST COMPLETE THE FOLLOWING.
Please provide us with FULL DETAILS for each "Yes" answer to any condition(s) checked in Sections H or I. In addition, please give details below of
last doctor visit and/or physical examination for ALL family members listed regardless of the date or reason. (Insert additional sheets if necessary.)
Question
Number
Name of Individual
Condition/Diagnosis
Date of
Onset
Date Treatment
Ended
Medication
Prescribed
Dosage
Still Taking
Medication
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
GR-67834-33 (9-07)
No
Yes
If you are providing additional sheets, check here
No
No
and insert the sheets before sealing this Enrollment form.
3
KS/MO - SGB
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 Managed Choice® POS Open Access and Aetna Open Choice® PPO: Aetna Life Insurance Company
• Aetna Dental Plan: Aetna Dental Inc.
• Life, Accidental Death & Dismemberment, disability, and all other health coverages: Aetna Life Insurance Company
2. I understand and agree that my employer’s application will determine coverage for the group and that there is no coverage unless
and until the group has been accepted and approved by Aetna subject to any state requirements.
3. 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 subject to evidence
of good health or medical information will not become effective until Aetna gives its written consent.
4. I understand and agree that this Enrollment/Change Request may be transmitted to Aetna 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 Aetna or its agent information concerning the medical history, prescription utilization history,
services or treatment provided to anyone listed on this Enrollment/Change Request form, including those involving mental health,
substance abuse and HIV/AIDS. 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 24 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.
PRIVACY NOTICE: Neither the U.S. brokers that handled this insurance nor
the insurers that have underwritten this insurance will disclose nonpublic
personal information concerning the buyer to nonaffiliates of the brokers or
insurers except as permitted by law.
5. 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. Any direct conflict between this form and the plan documents will
be resolved according to the terms which are most favorable to the member.
6. 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.
7. I understand and agree that, with certain exceptions described in the plan documents, 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.
8. Pre-existing conditions, when enrolled in this medical plan, may not be covered for ninety days.
Misrepresentation
9. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, denial of insurance and civil damages, as determined by a court
of law. Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files any
enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto may be guilty of fraud as determined by a court of law.
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 Kansas/Missouri Small Group Business (2-50 Eligible Employees) Employee Enrollment/Change
Form. I understand that, in the event I fail to sign this form within 31 days of my eligibility date 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.
Employee E-mail Address (optional)
Employee Signature
Date (Month/Day/Year)
X
GR-67834-33 (9-07)
4
KS/MO - SGB
