Humana Enrollment 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?No
Fillable fields0
Avg. time to fill out30 sec
Other namesemployee form, apply for small business stimulus, small business stimulus, humana enrollment form pdf

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

 

 

 

 

 

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฀฀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

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