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Form Name	Gn 80124 Cg Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	employee form, apply for small business stimulus, small business stimulus, humana enrollment form pdf

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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

m฀฀Change฀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:฀฀_______________________

m฀฀Change฀or฀Select฀Employee฀Primary฀Care฀Dentist฀(applicable฀to฀AZ,฀CA,฀FL,฀IL,฀and฀TX฀only):

฀Primary฀dentist:฀฀___________________________________________________฀฀ Facility฀number:฀฀______________________

m฀฀Change฀Basic฀Life฀beneﬁt/class฀to:฀฀฀Beneﬁt฀number:฀฀____________________________Class/Division:฀฀_______________________

฀฀฀ m฀฀Change฀Basic฀Life฀Beneﬁciary:฀฀Group฀number:฀฀________________________________

฀

Primary฀beneficiary฀name:฀฀฀ Last฀name฀

฀

฀฀

฀

First฀name฀

฀

MI฀

฀

Secondary฀beneﬁciary฀name:฀฀ Last฀name฀

฀

฀฀

฀

First฀name฀

฀

MI฀

m฀฀Change฀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:฀฀_______________________

m฀฀Cancel฀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฀฀Spouse฀terminates฀employment
m฀฀Employer฀contribution฀ceases	m฀฀Legal฀separation	m฀฀Spouse’s฀employer฀terminates฀coverage
m฀฀Dependent฀birth฀/฀adoption	m฀฀Divorce	m฀฀Spouse฀changes฀from฀full-time฀to฀฀
m฀฀Dependent฀change฀to฀full-time฀student	m฀฀Spouse฀deceased	฀ part-time฀employment
m฀฀Dependent฀change฀to฀full-time฀student	m฀฀Spouse฀deceased

m฀฀Other:฀฀__________________________

Change฀Address฀Information

Address฀change฀applies฀to:฀฀฀

฀m฀฀Employee฀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฀฀฀฀8/2007

Group฀Number

Social฀Security฀Number

Dependent฀Changes

Please฀complete฀this฀section฀for฀all฀dependent฀changes.
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

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

Primary฀care฀physician:฀฀__________________________________________________฀฀฀Physician฀ID:฀฀________________________

m฀฀Change฀or฀Select฀DHMO฀(applicable฀to฀AZ,฀CA,฀FL,฀IL,฀and฀TX฀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

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

Primary฀care฀physician:฀฀__________________________________________________฀฀฀Physician฀ID:฀฀________________________

m฀฀Change฀or฀Select฀DHMO฀(applicable฀to฀AZ,฀CA,฀FL,฀IL,฀and฀TX฀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

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

Primary฀care฀physician:฀฀__________________________________________________฀฀฀Physician฀ID:฀฀________________________

m฀฀Change฀or฀Select฀DHMO฀(applicable฀to฀AZ,฀CA,฀FL,฀IL,฀and฀TX฀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

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

Primary฀care฀physician:฀฀__________________________________________________฀฀฀Physician฀ID:฀฀________________________

m฀฀Change฀or฀Select฀DHMO฀(applicable฀to฀AZ,฀CA,฀FL,฀IL,฀and฀TX฀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฀฀฀฀8/2007

Gn 80124 Cg Form – Fill Out and Use

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