Humana Employee Change Form PDF Details

The Humana Employee Change Form serves as a crucial document for employees needing to update their personal or dependent information regarding various Humana insurance products. Designed with clarity in mind, it prompts users to print legibly and check applicable options throughout. Key sections of the form include updating beneficiary information for life insurance, selecting or changing a primary care physician or dentist, and making changes to vision, medical, dental, basic life, voluntary life, short-term income protection, and other coverages. Also included are areas to cancel coverage for various products, provide details on qualifying events such as marriage or the birth of a child, and update address information for the employee or their dependents. Additionally, the form allows for adjustments to be made to dependent information, highlighting its comprehensive nature in facilitating a wide range of changes to an employee’s benefits. Each section is meticulously designed to ensure that all possible needs are addressed, simplifying the process for both the employee and the administrative team handling these changes.

QuestionAnswer
Form NameHumana Employee Change Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshumana gn form, cg gn80124 cg change online, humana change form online, humana cg form pdf

Form Preview Example

Humana Employee Change Form

Please print clearly and fill in each applicable circle.

 

 

Current Medical Group number

Beneit 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 beneit/class to:

Beneit number: ____________________________ Class/Division: _______________________

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

 

Primary care physician: ______________________________________________

Physician ID: ________________________

m Change Dental beneit/class to: Beneit 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 beneit/class to: Beneit number: ____________________________Class/Division: _______________________

mChange Basic Life Beneiciary: Group number: ________________________________

Primary beneficiary name:

Last name

First name

MI

 

 

 

 

Secondary beneiciary name:

Last name

First name

MI

 

 

 

 

mChange Voluntary Life Beneiciary: Group number: ____________________________

Primary beneficiary name:

 

Last name

First name

MI

 

 

 

 

 

 

Secondary beneiciary name:

 

Last name

First name

MI

m Change Vision beneit/class to:

 

 

 

Beneit 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 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:

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

How to Edit Humana Employee Change Form Online for Free

If you need to fill out humana change form, it's not necessary to download and install any sort of programs - simply try using our online tool. Our expert team is relentlessly working to expand the tool and make it much easier for people with its many functions. Benefit from today's progressive possibilities, and find a heap of new experiences! Starting is easy! All you have to do is stick to these simple steps directly below:

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Step 2: This editor provides you with the opportunity to customize your PDF document in various ways. Transform it by adding your own text, adjust what is originally in the document, and include a signature - all at your convenience!

Completing this PDF needs focus on details. Ensure that all necessary areas are completed correctly.

1. Whenever filling in the humana change form, ensure to incorporate all of the important blanks in the associated area. It will help facilitate the work, making it possible for your information to be processed fast and accurately.

Filling out part 1 of gn cg cg form download

2. The third step is usually to complete these particular blank fields: Secondary beneiciary name Last name, First name, m Change Vision beneitclass to, ClassDivision, m Cancel My Coverage for the, Qualifying Event Information, Please indicate the qualifying, Qualifying event date, Reason for change m Rehire m, m Marriage m Legal separation m, Change Address Information, Address change applies to, m Employee only m Employee and all, m Only for the following dependent, and m Spouse terminates employment m.

Writing section 2 of gn cg cg form download

3. The next stage is straightforward - fill in every one of the blanks in m Only for the following dependent, New street address, City, Email address, GNCG, State, First name, Apt Suite PO Box number, Zip code, County, Phone number, and Reorder GNCG in order to complete this process.

Stage no. 3 of filling in gn cg cg form download

It's easy to make a mistake while completing the New street address, consequently make sure you take a second look prior to deciding to submit it.

4. This part comes with these particular blanks to type in your details in: Group Number, Social Security Number, Dependent Changes, Please complete this section for, Last name, First name, Date of birth, Social Security number Dependent, Gender m Female m Male, Relationship m Spouse m Child m, If disabled indicate reason, m Add or m Delete dependent tofrom, m Voluntary Life m Vision, m Dental m Basic Life, and Primary care physician Physician.

gn cg cg form download completion process outlined (step 4)

5. Last of all, the following final subsection is what you need to wrap up prior to closing the document. The fields here are the next: Primary care physician Physician, m Change or Select DHMO applicable, Primary dentist Facility number, Last name, First name, Date of birth, Social Security number Dependent, Gender m Female m Male, Relationship m Spouse m Child m, If disabled indicate reason, m Add or m Delete dependent tofrom, m Voluntary Life m Vision, m Dental m Basic Life, Primary care physician Physician, and m Change or Select DHMO applicable.

Step no. 5 in submitting gn cg cg form download

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