Form Ga 72000 – Fill Out and Use This PDF

Visit us at www.humana.com or www.humanadental.com

Humana Employee Enrollment Form - 20-99 Employees	GEORGIA

The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.

HMO and POS plans offered by Humana Employers Health Plan of Georgia, Inc. , and/or insured or administered by Humana Insurance Company. PPO and Classic Medical plans, Life, and Vision plans insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company, Humana Insurance Company, CompBenefits Insurance Company or CompBenefits of Georgia, Inc. CompBenefits Vision plan insured and administered by CompBenefits Insurance Company.

Please print clearly and fill in each applicable circle.

Proposed effective date:

_ _ / _ _ / _ _ _ _

Company name

Company city

State

Enrollment Information

GA-72000-EI 3/2008

Height

Weight

Full-time

Disabled?

Relationship

Last name, First name MI

(ft / in)

(lbs.)

Gender

student?

Date of birth

If yes, indicate reason.

Employee

/

m F

N/A

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

Spouse

/

m F

N/A

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

Child

/

m F

m N

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

m Y

Child

/

m F

m N

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

m Y

Child

/

m F

m N

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

m Y

Other (specify):

/

m F

m N

_ _ / _ _ / _ _ _ _

m N

Reason:

m M

m Y

m Y

EMPLOYEE INFORMATION:

HOURS WORKED PER WEEK:

m RETIREE

DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _

SSN #

Street address

APT / Suite / Box

City

State

Zip code

Phone #

(

)

Language: m English m Spanish

Email address

Medical

Group #:

Benefit #:

Class/Div:

GA-72000-MD 3/2008

Coverage type:

m Employee only

m Employee and spouse

m Employee and child(ren)

Plan name

m Family

m NO COVERAGE (complete waiver)

1. Prior medical coverage during the past 18 months (individual or other group coverage)? m N m Y

Prior medical insurance carrier name

Policy #

Prior coverage type:

Effective date

_ _ / _ _ / _ _ _ _

m Employee only

m Employee and spouse

Term date _ _ / _ _ / _ _ _ _

m Employee and child(ren) m Family

2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)? m N m Y

Other Medical Insurance carrier name	Policy #	Other coverage type:		Effective date _ _ / _ _ / _ _ _ _
		m Employee only	m Employee and spouse
				Term date _ _ / _ _ / _ _ _ _
		m Employee and child(ren)	m Family

3. Medicare coverage:

Employee coverage:	m N	m Y	Medicare ID		Effective date _ _ / _ _ / _ _ _ _			Term date	_ _ / _ _ / _ _ _ _
Spouse coverage:	m N	m Y	Medicare ID		Effective date _ _ / _ _ / _ _ _ _			Term date	_ _ / _ _ / _ _ _ _
Health Savings Account			Group #:	Benefit #:		Class/Div:			GA-72000-HA 3/2008

If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details.

Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can ind additional information on HSAs on Humana.com. Select the Quick Link for Spending Account information on the Member page.

	Dental	Group #:		Benefit #:		Class/Div:	GA-72000-HD 3/2008
	Coverage type:	m Employee only	m Employee and spouse		m Employee and child(ren)		Plan name
		m Family	m NO COVERAGE (complete waiver)
	Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y
	Prior dental insurance carrier name			Prior coverage type:		Effective date	Policy #
				m Employee only		_ _ / _ _ / _ _ _ _
				m Employee and spouse
	Prior orthodontia coverage in the past 12 months?					Term date	Prior carrier phone # (	)
				m Employee and child(ren)
	m N m Y			m Family		_ _ / _ _ / _ _ _ _
	GA-72000 12/2007				1		Reorder# GA-51340-HH	12/2008

Basic Life

Group #:

Benefit #:

Class/Div:

GA-72000-BL

3/2008

Primary beneiciary name (Last, First MI)

Secondary beneiciary name (Last, First MI)

Class (employer will provide you

Annual salary (if applicable)

Basic dependent life? m No

m Yes

with this information if needed)

$

If no, complete waiver section.

Voluntary Life

Group #:

Benefit #:

Class/Div:

GA-72000-VL

3/2008

Voluntary employee life

Amount (min $15,000)

Primary beneiciary name (Last, First MI)

Secondary beneiciary name (Last, First MI)

coverage? m N m Y

$

Voluntary spouse life

Amount (min. $5,000)

Voluntary child(ren) life coverage?

Annual employee salary (if applicable)

coverage? m N m Y

$

m N m Y

$

Vision

Group #:

Benefit #:

Class/Div:

GA-72000-VS

3/2008

Coverage type:

m Employee only

m Employee and spouse

m Employee and child(ren)

Plan name

m Family

m NO COVERAGE (complete waiver)

Medical Health History

GA-72000-MH

3/2008

This information should not be submitted more than 60 days prior to the effective date.

1. Within the past 24 months have you or any dependent	2. Within the past 24 months have you	3. Have you or any dependent to be
to be covered been diagnosed or been treated for	or any dependent to be covered been	covered incurred medical expenses
an illness or injury, had surgery or hospitalization	prescribed medication? m N m Y	in excess of $7,500 in the past 12
recommended, or are currently pregnant? m N m Y		months? m N m Y

If you answered “yes” to any of the questions above, please provide details below and specify the question number. Attach additional signed and dated sheets if necessary.

Question # & letter	Person treated (Last name, First name)
Condition		Treatments received
Medications prescribed		Current or future treatments or medications
Date diagnosed _ _ / _ _ / _ _ _ _		Date last seen by a doctor _ _ / _ _ / _ _ _ _

Waiver (refusal of coverage)GA-72000-WV 3/2008

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I proclaim that I was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage. If I have waived any coverage offered to me or my dependents, my signature is evidence of this action.

	I hereby waive coverage for (check all that apply):				I decline to apply for group coverage because of:
	Medical for:	m Myself	m My spouse	m My dependent child(ren)	m Spousal coverage
	Dental for:	m Myself	m My spouse	m My dependent child(ren)	m Medicare supplement
	Basic Life for: m Myself		m My spouse	m My dependent child(ren)	m Individual coverage
	Vision for:	m Myself	m My spouse	m My dependent child(ren)	m Coverage under another carrier’s plan provided by my employer
	Health Savings Account for: m Myself				m Other:
	Agreement				GA-72000-AA 3/2008

True and complete acknowledgement

I understand, agree and represent:

•I have read this document or it has been read to me and answers provided are true and complete to the best of my knowledge and belief.

•Neither my employer nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other rights and requirements.

•If this application for coverage is accepted, coverage will be effective on the date speciied by Humana on the certiicate of coverage/certiicate of insurance. If I have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment with in 31 days after the qualifying event.

•In the event that I should decide to apply for coverage hereafter, that subsequent application shall be subject to the applicable terms and conditions of the master group contract(s) or plan provisions which may require additional limitations and waiting periods.

•I may be required to furnish, at my own expense, evidence of health status satisfactory to Humana.

•If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my dependents provided that I request enrollment within 31 days after my other coverage ends.

•Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future application for coverage.

•If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize Humana or its banking partners to provide my account number to my employer for the purposes of depositing any contributions.

•Any intentional misrepresentation contained herein relied on by Humana may be used to reduce or deny a claims or void the contract within the contestable period if such misrepresentation materially affected the acceptance of the risk.

•Medical coverage will not be declined due to health status.

•I have received a copy of the plan provider directory and disclosure that includes provider limitation rules and any inancial arrangements with providers.

GA-72000 12/2007

2

Reorder# GA-51340-HH 12/2008

Agreement

GA-72000-AA 3/2008

Authorization

My dependents and I authorize any third party to have information regarding myself and my dependents. This includes any medical or non-medical information and to share any and all such information with Humana, its reinsurer or its legal representatives, and its afiliates.

My dependents and I understand and agree:

•The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for beneits under an existing policy and plan administration.

•Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc. or other persons or organizations performing health care operations or business or legal services in connection with an application, claim or as may be otherwise lawfully required, or as I (we) may further authorize. Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements.

•A photographic copy of this authorization shall be as valid as the original.

•This authorization shall be valid for two years from the date shown below and I have the right to revoke this authorization at any time by writing to Humana’s

Privacy Ofice.

This document, together with any supplements, will form part of any contract and be the basis for any certiicate of coverage/certiicate of insurance issued.

If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the inability to obtain the necessary information.

Employee or legal representative signature: _____________________________________________ Date: ____________________

Name and relationship of legal representative: _______________________________________________________________________

Spouse signature: _________________________________________________________________ Date: ____________________

(Only if selecting Life coverage over the guarantee issue amount.)

GA-72000 12/2007

3

Reorder# GA-51340-HH 12/2008