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.
Question | Answer |
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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 |
HumanaEmployeeChangeForm
Pleaseprintclearlyandfillineachapplicablecircle. |
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CurrentMedicalGroupnumber |
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Benefitnumber |
Class/Division |
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CurrentDentalGroupnumber |
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ProposedEffectiveDateforchange:____/____/________ |
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Companyname |
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Companycity |
State |
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EmployeeInformationandChanges |
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Pleaseprovideemployeeinformationandindicateallapplicableemployeechanges. |
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Lastname |
Firstname |
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MI |
SocialSecuritynumber |
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mChangeMedicalbenefit/classto:Benefitnumber:____________________________ Class/Division:_______________________
mChangeorSelectEmployeePrimaryCarePhysician(HMOandPOSonly):
Primarycarephysician:______________________________________________PhysicianID:________________________
mChangeDentalbenefit/classto:Benefitnumber:____________________________ Class/Division:_______________________
mChangeorSelectEmployeePrimaryCareDentist(applicabletoAZ,CA,FL,IL,andTXonly):
Primarydentist:___________________________________________________ Facilitynumber:______________________
mChangeBasicLifebenefit/classto:Benefitnumber:____________________________Class/Division:_______________________
mChangeBasicLifeBeneficiary:Groupnumber:________________________________
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Primarybeneficiaryname: Lastname |
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Firstname |
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MI |
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Secondarybeneficiaryname: Lastname |
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Firstname |
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MI |
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mChangeVoluntaryLifeBeneficiary:Groupnumber:____________________________ |
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Primarybeneficiaryname: Lastname |
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Firstname |
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MI |
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Secondarybeneficiaryname: Lastname |
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Firstname |
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MI |
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mChangeVisionbenefit/classto:Benefitnumber:____________________________ Class/Division:_______________________
mVisionmHealthSavingsAccount(HSA)mHealthCareFSAmDependentCareFSA
QualifyingEventInformation
Pleaseindicatethequalifyingeventdateandreasonforemployeeordependentchangesbelow.
Qualifyingeventdate:____/____/________ |
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Reasonforchange: |
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mMarriage |
mSpouseterminatesemployment |
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mEmployercontributionceases |
mLegalseparation |
mSpouse’semployerterminatescoverage |
mDependentbirth/adoption |
mDivorce |
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mSpousedeceased |
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mOther:__________________________
ChangeAddressInformation
Addresschangeappliesto:
mEmployeeonlymEmployeeandallcovereddependents
mOnlyforthefollowingdependent(pleaseprintfullname):Lastname |
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Firstname |
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MI |
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Newstreetaddress |
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Apt/Suite/POBoxnumber |
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City |
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State |
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Zipcode |
County |
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Emailaddress |
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Phonenumber |
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1 |
GroupNumber
SocialSecurityNumber
DependentChanges
Pleasecompletethissectionforalldependentchanges. |
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Lastname |
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Firstname |
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MI |
Dateofbirth__/__/____ |
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SocialSecuritynumber |
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Gender:mFemalemMale |
Relationship:mSpousemChildmOther: |
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Ifdisabled,indicatereason: |
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mAddormDeletedependentto/frommycurrentplanforthefollowingproducts:mMedical |
mDental |
mBasicLife |
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mVoluntaryLife |
mVision |
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mChangeorSelectPrimaryCarePhysician(HMOandPOSonly):
Primarycarephysician:__________________________________________________PhysicianID:________________________
mChangeorSelectDHMO(applicabletoAZ,CA,FL,IL,andTXonly):
Primarydentist:_______________________________________________________ Facilitynumber:______________________
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Lastname |
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Firstname |
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MI |
Dateofbirth__/__/____ |
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SocialSecuritynumber |
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Gender:mFemalemMale |
Relationship:mSpousemChildmOther: |
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Ifdisabled,indicatereason: |
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mAddormDeletedependentto/frommycurrentplanforthefollowingproducts:mMedical |
mDental |
mBasicLife |
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mVoluntaryLife |
mVision |
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mChangeorSelectPrimaryCarePhysician(HMOandPOSonly):
Primarycarephysician:__________________________________________________PhysicianID:________________________
mChangeorSelectDHMO(applicabletoAZ,CA,FL,IL,andTXonly):
Primarydentist:_______________________________________________________ Facilitynumber:______________________
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Lastname |
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Firstname |
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MI |
Dateofbirth__/__/____ |
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SocialSecuritynumber |
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Gender:mFemalemMale |
Relationship:mSpousemChildmOther: |
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Ifdisabled,indicatereason: |
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mAddormDeletedependentto/frommycurrentplanforthefollowingproducts:mMedical |
mDental |
mBasicLife |
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mVoluntaryLife |
mVision |
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mChangeorSelectPrimaryCarePhysician(HMOandPOSonly):
Primarycarephysician:__________________________________________________PhysicianID:________________________
mChangeorSelectDHMO(applicabletoAZ,CA,FL,IL,andTXonly):
Primarydentist:_______________________________________________________ Facilitynumber:______________________
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Lastname |
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Firstname |
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MI |
Dateofbirth__/__/____ |
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SocialSecuritynumber |
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Gender:mFemalemMale |
Relationship:mSpousemChildmOther: |
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Ifdisabled,indicatereason: |
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mAddormDeletedependentto/frommycurrentplanforthefollowingproducts:mMedical |
mDental |
mBasicLife |
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mVoluntaryLife |
mVision |
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mChangeorSelectPrimaryCarePhysician(HMOandPOSonly):
Primarycarephysician:__________________________________________________PhysicianID:________________________
mChangeorSelectDHMO(applicabletoAZ,CA,FL,IL,andTXonly):
Primarydentist:_______________________________________________________ Facilitynumber:______________________
Employeeorlegalrepresentativesignature:______________________________________________ Date:______________________
Nameandrelationshipoflegalrepresentative:_________________________________________________________________________
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