Humana Employee Enrollment Form PDF Details

The Humana Employee Enrollment Form serves as a comprehensive document designed for businesses with 51-99 employees in Wisconsin, streamlining the process for employees to enroll in various health insurance plans. Highlighting an array of insurance options, it caters to a broad spectrum of healthcare and dental needs including PPO, Classic, and Indemnity Medical plans, as well as Life and Vision plans through Humana Insurance Company, and Medical HMO plans via Humana Wisconsin Health Organization Insurance Corporation. The form meticulously guides the applicant through each step, requesting detailed personal information, coverage selections, and previous health insurance data to ensure a tailored healthcare solution. Additionally, it encompasses options for Health Savings Accounts (HSAs), providing a versatile financial tool for managing healthcare expenses. The importance of accurate and truthful completion of the form is underscored by its role in determining eligibility, coverage levels, and potentially affecting future claims or coverage adjustments based on the provided information. Acknowledging the legal and contractual significance of the information provided, the form also includes waivers for those opting out of certain coverages, and detailed agreements outlining the applicant's understanding of terms, conditions, and privacy implications, cementing the form's role as a critical element in the enrollment process in Humana health plans.

QuestionAnswer
Form NameHumana Employee Enrollment Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshumana, Humanas, WI-72000-HD, reinsuring

Form Preview Example

Visit us at www.humana.com or www.humanadental.com

Humana Employee Enrollment Form - 51-99 Employees (10-99 existing business)

WISCONSIN

 

 

The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.

PPO, Classic, and Indemnity Medical plans, Life and Vision plans insured or administered by Humana Insurance Company. Medical HMO plans offered by Humana Wisconsin Health Organization Insurance Corporation. Medical POS plans offered by Humana Wisconsin Health Organization Insurance Corporation and insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company.

Please print clearly and fill in each applicable circle.

Proposed effective date: _ _ / _ _ / _ _ _ _

Company name

 

 

 

 

 

 

 

 

 

 

 

 

Company city

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enrollment Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WI-72000-EI 4/2008

 

 

 

 

 

 

 

 

 

Height

Weight

 

 

 

Full-time

 

 

 

 

Disabled?

Relationship

 

Last name, First name MI

 

(ft / in)

(lbs.)

 

Gender

student?

Date of birth

 

If yes, indicate reason.

Employee

 

 

 

 

 

 

 

 

/

 

 

 

m F

N/A

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

 

 

 

Spouse

 

 

 

 

 

 

 

 

/

 

 

 

m F

N/A

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

 

 

 

Child

 

 

 

 

 

 

 

 

/

 

 

 

m F

m N

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

m Y

 

 

 

Child

 

 

 

 

 

 

 

 

/

 

 

 

m F

m N

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

m Y

 

 

 

Child

 

 

 

 

 

 

 

 

/

 

 

 

m F

m N

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

m Y

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

/

 

 

 

m F

m N

_ _ / _ _ / _ _ _ _

m N

 

Reason:

 

 

 

 

 

 

 

 

 

 

 

 

m M

m Y

m Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE INFORMATION:

HOURS WORKED PER WEEK:

 

m RETIREE

DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _

SSN #

 

 

Street address

 

 

 

 

 

 

 

 

 

 

 

 

APT / Suite / Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip code

 

 

 

 

Phone #

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language: m English m Spanish

 

 

Email address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical

Group #:

 

 

 

 

 

 

 

Benefit #:

 

 

 

 

Class/Div:

 

 

 

WI-72000-MD 4/2008

Coverage type:

m Employee only

m Employee and spouse

m Employee and child(ren)

 

Plan name

 

 

 

 

 

m Family

 

 

 

m NO COVERAGE (complete waiver)

 

 

 

 

 

 

 

 

 

1. Prior medical coverage during the past 18 months (individual or other group coverage)? m N m Y

 

 

 

Prior medical insurance carrier name

Policy #

 

Prior coverage type:

 

 

 

Effective date _ _ / _ _ / _ _ _ _

 

 

 

 

 

 

 

 

 

 

m Employee only

m Employee and spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Term date _ _ / _ _ / _ _ _ _

 

 

 

 

 

 

 

 

 

 

m Employee and child(ren) m Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)? m N m Y

Other Medical Insurance carrier name

Policy #

Other coverage type:

 

Effective date _ _ / _ _ / _ _ _ _

 

 

m Employee only

m Employee and spouse

 

 

 

 

 

Term date _ _ / _ _ / _ _ _ _

 

 

m Employee and child(ren)

m Family

 

 

 

 

 

3. Medicare coverage:

Employee coverage:

m N

m Y

Medicare ID

 

Effective date _ _ / _ _ / _ _ _ _

Term date

_ _ / _ _ / _ _ _ _

 

 

 

 

 

 

 

 

 

Spouse coverage:

m N

m Y

Medicare ID

 

Effective date _ _ / _ _ / _ _ _ _

Term date

_ _ / _ _ / _ _ _ _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Savings Account

Group #:

Benefit #:

Class/Div:

 

 

WI-72000-HA 4/2008

If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details.

Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can find additional information on HSAs on Humana.com. Select the Quick Link for Spending Account information on the Member page.

Do you elect the Health Savings Account? m N m Y (If no, complete waiver.)

Beneficiary for this account will be the employee’s estate. You may change beneficiary information on file with the bank that administers the HSA once the account is established.

Dental

Group #:

Benefit #:

Class/Div:

WI-72000-HD 4/2008

Coverage type:

m Employee only

m Employee and spouse

m Employee and child(ren)

Plan name

 

m Family

m NO COVERAGE (complete waiver)

 

Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y

Prior dental insurance carrier name

Prior orthodontia coverage in the past 12 months? m N m Y

Prior coverage type:

mEmployee only

mEmployee and spouse

mEmployee and child(ren)

mFamily

Effective date

Policy #

 

_ _ / _ _ / _ _ _ _

 

 

 

 

 

Term date

Prior carrier phone # (

)

_ _ / _ _ / _ _ _ _

 

 

 

 

 

WI-72000 4/2008

1

Reorder# WI-51340-HH 11/2008

Last name:

First name:

Basic Life

 

Group #:

 

 

 

 

 

 

Benefit #:

 

 

 

Class/Div:

 

 

 

WI-72000-BL 4/2008

Primary beneficiary name (Last, First MI)

 

 

 

 

 

Secondary beneficiary name (Last, First MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class (employer will provide you

 

Annual salary (if applicable)

Basic dependent life? m N m Y

with this information if needed)

 

$

 

 

 

 

If no, complete waiver section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voluntary Life

 

Group #:

 

 

 

 

Benefit #:

 

 

 

Class/Div:

 

 

 

WI-72000-VL 4/2008

Voluntary employee life

Amount (min $15,000)

Primary beneficiary name (Last, First MI)

Secondary beneficiary name (Last, First MI)

coverage? m N m Y

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voluntary spouse life

Amount (min. $5,000)

Voluntary child(ren) life coverage?

Annual employee salary (if applicable)

coverage? m N m Y

$

 

 

 

m N m Y

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision

 

Group #:

 

 

 

 

 

 

Benefit #:

 

 

 

Class/Div:

 

 

 

WI-72000-VS 4/2008

Coverage type:

m Employee only

m Employee and spouse

m Employee and child(ren)

 

 

Plan name

 

 

m Family

m NO COVERAGE (complete waiver)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Health History

 

 

 

 

 

 

 

 

 

 

 

 

WI-72000-MH 4/2008

This information should not be submitted more than 60 days prior to the effective date.

 

 

 

 

 

1. Within the past 24 months have you or any dependent

 

2. Within the past 24 months have you

 

3. Have you or any dependent to be

to be covered had or been treated for an illness or

 

 

or any dependent to be covered been

 

 

 

covered incurred medical expenses

injury, had surgery or hospitalization recommended, or

 

prescribed medication? m N m Y

 

 

 

in excess of $7,500 in the past 12

are currently pregnant?

m N m Y

 

 

 

 

 

 

 

 

 

 

 

months? m N m Y

If you answered “yes” to any of the questions above, please provide details below and specify the question number. Attach additional signed and dated sheets if necessary.

Question # & letter

Person treated (Last name, First name)

 

 

 

Condition

 

Treatments received

 

 

 

Medications prescribed

 

Current or future treatments or medications

 

 

 

Date diagnosed _ _ / _ _ / _ _ _ _

 

Date last seen by a doctor _ _ / _ _ / _ _ _ _

 

 

 

Waiver (refusal of coverage)WI-72000-WV 4/2008

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I proclaim that I was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage. If I have waived any coverage offered to me or my dependents, my signature is evidence of this action.

 

I hereby waive coverage for (check all that apply):

I decline to apply for group coverage because of:

 

Medical for:

m Myself

m My spouse

m My dependent child(ren)

m Spousal coverage

 

Dental for:

m Myself

m My spouse

m My dependent child(ren)

m Medicare supplement

 

Basic Life for:m Myself

m My spouse

m My dependent child(ren)

m Individual coverage

 

Vision for:

m Myself

m My spouse

m My dependent child(ren)

m Coverage under another carrier’s plan provided by my employer

 

Health Savings Account for: m Myself

 

m Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

Agreement

 

 

 

WI-72000-AA 4/2008

True and complete acknowledgement

I understand, agree and represent:

I have read this document or it has been read to me and answers provided are true and complete to the best of my knowledge and belief.

Neither my employer nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other rights and requirements.

If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the certificate of coverage/certificate of insurance.

If I have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment within 31 days after the qualifying event.

In the event that I should decide to apply for coverage hereafter, that subsequent application shall be subject to the applicable terms and conditions of the master group contract(s) or plan provisions which may require additional limitations and waiting periods.

I may be required to furnish, at my own expense, evidence of health status satisfactory to Humana.

If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my dependents provided that I request enrollment within 31 days after my other coverage ends.

Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future application for coverage.

If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize Humana or its banking partners to provide my account number to my employer for the purposes of depositing any contributions.

Any misrepresentation contained herein relied on by Humana may be used to reduce or deny a claims or void the contract within the contestable period if such misrepresentation materially affected the acceptance of the risk.

Authorization

I authorize any third party to have information regarding myself. This includes any medical or non-medical information and to share any and all such information with Humana, its reinsurer or its legal representatives, and its affiliates.

WI-72000 4/2008

2

Reorder# WI-51340-HH 11/2008

Last name:

First name:

Agreement

WI-72000-AA 4/2008

My dependents and I understand and agree:

The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for benefits under an existing policy and plan administration.

Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc. or other persons or organizations performing health care operations or business or legal services in connection with an application, claim or as may be otherwise lawfully required, or as I (we) may further authorize. Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements.

A photographic copy of this authorization shall be as valid as the original.

This authorization shall be valid for two years from the date shown below and I have the right to revoke this authorization at any time by writing to Humana’s Privacy Office.

This document, together with any supplements, will form part of any contract and be the basis for any certificate of coverage/certificate of insurance issued.

Signature - please sign below if enrolling or waiving group coverage.

 

WI-72000-SA 4/2008

If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the

inability to obtain the necessary information.

 

 

Employee or legal representative signature: _____________________________________________

Date: ____________________

Name and relationship of legal representative: _______________________________________________________________________

WI-72000 4/2008

3

Reorder# WI-51340-HH 11/2008

How to Edit Humana Employee Enrollment Form Online for Free

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Step 2: When you open the tool, there'll be the form made ready to be filled out. In addition to filling out various blank fields, you could also do other sorts of actions with the Document, specifically adding any text, modifying the initial textual content, adding illustrations or photos, affixing your signature to the PDF, and more.

This PDF doc will involve specific information; to ensure consistency, you should take note of the recommendations listed below:

1. You will want to complete the HSA accurately, so be attentive while filling in the parts that contain all of these fields:

WI-72000-AA conclusion process clarified (stage 1)

2. Given that the last section is completed, you're ready to insert the needed specifics in Language m English m Spanish, Email address, Group, Medical Coverage type m Employee, m NO COVERAGE complete waiver, m Family, ClassDiv, Benefit, Plan name, WIMD, Prior coverage type m Employee, m Employee and spouse, Effective date, Term date, and Other medical coverage in effect so you're able to progress to the 3rd step.

Find out how to prepare WI-72000-AA portion 2

3. This 3rd part is considered relatively straightforward, Health Savings Account If you have, Beneficiary for this account will, Group, Dental Coverage type m Employee, m NO COVERAGE complete waiver, m Family, ClassDiv, Benefit, Policy, Plan name, WIHD, Prior orthodontia coverage in the, Prior coverage type m Employee, Effective date Term date, and Prior carrier phone - all these fields has to be completed here.

Filling in segment 3 of WI-72000-AA

4. To go onward, the next stage involves filling in a couple of form blanks. These comprise of Basic Life Primary beneficiary, Group, Benefit, Last name, First name, ClassDiv, WIBL, Secondary beneficiary name Last, Class employer will provide you, Annual salary if applicable, Basic dependent life m N m Y If no, Group, Voluntary Life Voluntary employee, Amount min Amount min, and Benefit, which are essential to moving forward with this particular form.

Completing section 4 in WI-72000-AA

People frequently make mistakes when filling in Voluntary Life Voluntary employee in this area. You should definitely revise whatever you enter right here.

5. Since you get close to the end of the file, there are several more things to complete. In particular, Medications prescribed, Current or future treatments or, Date diagnosed, Date last seen by a doctor, Waiver refusal of coverage I, m Spousal coverage m Medicare, I decline to apply for group, WIWV, WIAA, Agreement True and complete, and I have read this document or it must be filled in.

Agreement True and complete, WIWV, and I decline to apply for group inside WI-72000-AA

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