Gn 80124 Cg Form PDF Details

Gn 80124 cg form is a government form that is used to request reimbursement for expenses. The form can be used to request reimbursement for travel expenses, lodging expenses, or other business-related expenses. Reimbursement for these types of expenses can often be tax-deductible, so it's important to accurately complete the Gn 80124 cg form in order to receive the correct reimbursement amount. Failure to properly complete the form may result in a delay or denial of payment.

The following are some particulars about gn 80124 cg form. You may find out its size, the average time to prepare the form, the fields you'll have to fill in, and so forth.

QuestionAnswer
Form NameGn 80124 Cg Form
Form Length2 pages
Fillable?Yes
Fillable fields200
Avg. time to fill out20 min 17 sec
Other namesemployee comp chnage form, humana employee enrollment form, small business stimulus, humana continuity of care form for state of florida

Form Preview Example

Humana Employee Change Form

Please print clearly and fill in each applicable circle.

 

 

Current Medical Group number

Benefit number

Class/Division

 

 

 

Current Dental Group number

Proposed Effective Date for change:

__ __ / __ __ / __ __ __ __

 

 

 

Company name

Company city

State

Employee Information and Changes

Please provide employee information and indicate all applicable employee changes.

Last name

First name

MI

Social Security number

 

 

 

 

mChange Medical benefit/class to: Benefit number: ____________________________ Class/Division: _______________________

m Change or Select Employee Primary Care Physician (HMO and POS only):

Primary care physician: ______________________________________________ Physician ID: ________________________

m Change Dental benefit/class to: Benefit number: ____________________________ Class/Division: _______________________

mChange or Select Employee Primary Care Dentist (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only): Primary dentist: ___________________________________________________ Facility number: ______________________

mChange Basic Life benefit/class to: Benefit number: ____________________________Class/Division: _______________________

mChange Basic Life Beneficiary: Group number: ________________________________

Primary beneficiary name:

Last name

First name

MI

 

 

 

 

Secondary beneficiary name:

Last name

First name

MI

 

 

 

 

mChange Voluntary Life Beneficiary: Group number: ____________________________

Primary beneficiary name:

 

Last name

First name

MI

 

 

 

 

 

 

Secondary beneficiary name:

 

Last name

First name

MI

m Change Vision benefit/class to:

 

 

 

Benefit number: ____________________________ Class/Division: _______________________

mCancel My Coverage for the following products: m Medical m Dental m Basic Life m Voluntary Life m Short-term Income Protection m Vision m Health Savings Account (HSA) m Health Care FSA m Dependent Care FSA

Qualifying Event Information

Please indicate the qualifying event date and reason for employee or dependent changes below.

Qualifying event date: __ __ / __ __ / __ __ __ __

Reason for change:

 

m Re-hire

m Marriage

m Employer contribution ceases

m Legal separation

m Dependent birth / adoption

m Divorce

m Dependent change to full-time student

m Spouse deceased

mSpouse terminates employment

mSpouse’s employer terminates coverage

mSpouse changes from full-time to part-time employment

mOther: __________________________

Change Address Information

Address change applies to:

mEmployee only m Employee and all covered dependents

m Only for the following dependent (please print full name): Last name

 

First name

MI

 

 

 

 

 

 

New street address

 

 

 

Apt / Suite / PO Box number

 

 

 

 

 

 

City

State

Zip code

County

 

 

 

 

 

 

 

Email address

 

 

 

Phone number

 

 

 

 

 

 

 

GN-80124-CG 11/2006

1

Reorder# GN-99955-CG 3/2009

Group Number

Dependent Changes

Please complete this section for all dependent changes.

Social Security Number

1 Last name

First name

MI

Date of birth

_ _ / _ _ / _ _ _ _

 

Social Security number

Gender: m Female m Male

Relationship: m Spouse

m Child m Other:

 

 

 

 

 

 

Dependent status (if applicable):

m Full-time student m Disabled

If disabled, indicate reason:

 

 

 

 

 

m Add or m Delete dependent to/from my current plan for the following products: m Medical

m Dental

m Basic Life

 

 

 

m Voluntary Life

m Vision

 

mChange or Select Primary Care Physician (HMO and POS only):

Primary care physician: __________________________________________________ Physician ID: ________________________

mChange or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):

Primary dentist: _______________________________________________________ Facility number: ______________________

 

 

 

 

 

 

 

2 Last name

First name

MI

Date of birth

_ _ / _ _ / _ _ _ _

 

 

Social Security number

Gender: m Female m Male

Relationship: m Spouse

m Child m Other:

 

 

 

 

 

 

 

 

Dependent status (if applicable):

m Full-time student m Disabled

If disabled, indicate reason:

 

 

 

 

 

 

 

m Add or m Delete dependent to/from my current plan for the following products: m Medical

m Dental

m Basic Life

 

 

 

 

m Voluntary Life

m Vision

 

mChange or Select Primary Care Physician (HMO and POS only):

Primary care physician: __________________________________________________ Physician ID: ________________________

mChange or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):

Primary dentist: _______________________________________________________ Facility number: ______________________

3 Last name

First name

MI

Date of birth

_ _ / _ _ / _ _ _ _

 

Social Security number

Gender: m Female m Male

Relationship: m Spouse

m Child m Other:

 

 

 

 

 

 

Dependent status (if applicable):

m Full-time student m Disabled

If disabled, indicate reason:

 

 

 

 

 

m Add or m Delete dependent to/from my current plan for the following products: m Medical

m Dental

m Basic Life

 

 

 

m Voluntary Life

m Vision

 

mChange or Select Primary Care Physician (HMO and POS only):

Primary care physician: __________________________________________________ Physician ID: ________________________

mChange or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):

Primary dentist: _______________________________________________________ Facility number: ______________________

4 Last name

First name

MI

Date of birth

_ _ / _ _ / _ _ _ _

 

Social Security number

Gender: m Female m Male

Relationship: m Spouse

m Child m Other:

 

 

 

 

 

 

Dependent status (if applicable):

m Full-time student m Disabled

If disabled, indicate reason:

 

 

 

 

 

m Add or m Delete dependent to/from my current plan for the following products: m Medical

m Dental

m Basic Life

 

 

 

m Voluntary Life

m Vision

 

mChange or Select Primary Care Physician (HMO and POS only):

Primary care physician: __________________________________________________ Physician ID: ________________________

mChange or Select DHMO (applicable to AL, AZ, CA, FL, GA, IL, IN, KS, KY, MO, NC, OH, TN, TX and WV only):

Primary dentist: _______________________________________________________ Facility number: ______________________

Signature - please sign below if requesting changes

Employee or legal representative signature: ______________________________________________ Date: ______________________

Name and relationship of legal representative: _________________________________________________________________________

GN-80124-CG 11/2006

2

Reorder# GN-99955-CG 3/2009

Print&Submit

Reset

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small business stimulus gaps to complete

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