Department of Human Resources 4855 Bloom Ave  White Bear Lake, MN 55110  (651) 407-7548  Fax (651) 407-7541 

Major Benefits Enrollment Form

Please fill out all areas completely and legibly. BARGAINING GROUP: ______

Name / Gender: M
F / Social Security #
- - / Single Married
Address / City / State / Zip
US Citizen? Y N / Home Phone / Date of Birth

Medical (select one type of coverage at either single or family level)

Single Coverage / Family Coverage
Open Access
National One
Choice

WAIVE MEDICALCOVERAGE?

Dental

Single or Family Coverage? / Single Family

Life

Elections / Amount
x / Basic Life / $
Supplemental Life
Dependent Life
x / Long Term Disability / 2/3 of Salary

Dependent Information

Name (Last, First, Middle In.) / Social Security Number / Gender
M/F / Date of Birth / Relationship to Employee / Enrolling in?
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental

Do all of the dependent(s) listed above reside at the same address as the applicant? Y N

If no, list dependent(s) name and address: ______

Are any of the above listed dependent(s) under the age of 26 married? Y N

If yes, list dependent(s) names: ______

Are any of the above listed dependent(s) disabled (eligible for guaranteed coverage)? Y N

If yes, list dependent(s) names: ______

At the time of your effective date with HealthPartners, will you, your spouse and/or dependent(s) be insured by any other health insurance company? Y N (If yes, please provide a copy of your insurance card and fill out next section indicating coverage details.)

In the 18 months prior to your effective date with Health Partners, have you, your spouse and/or dependent(s) been insured by any other health insurance company? Y N (If yes, please provide a copy of your insurance card and fill out the next section indicating coverage details.)

Applicant / Name of Insured / Current/Previous Insurance Provider / ID Number / Coverage Start Date / Coverage End Date

Beneficiary Information

Your death benefits are to be paid to:
Primary Beneficiary(ies) / If primary beneficiary(ies) is/are not living at the time of your death, benefits are to be paid to: Secondary Beneficiary(ies)
NAME (LAST, FIRST, MIDDLE) / Relationship / Percent of Benefit / NAME (LAST, FIRST, MIDDLE) / Relationship / Percent of Benefit
* SPOUSE’S SIGNATURE (only if not a primary beneficiary) / Date:

Medical Acknowledgement: CONDITIONS OF COVERAGE: I HEREBY APPLY FOR COVERAGE ON THE BASIS OF THE STATEMENTS AND ANSWERS TO THE QUESTIONS HEREIN. I hereby declare all answers to be true and complies with the best of my knowledge. Subject to revocation by me by written notice to my employer, I authorize the required deduction (if any) from my wages. I have read and agree with the terms as stated on this application. By acceptance of coverage and upon signing this Enrollment Form, I authorize HealthPartners, and others it designates, to share information about me with any medical provider, plan sponsor, or other entity, where such information is reasonably necessary for treatment, payment or health care operations. I understand that HealthPartners may release information regarding services provided under my health benefits contract when requested by the organization sponsoring my benefits plan. I understand that providing false information or omission of relevant information in this application may result in the denial of claims, cancellation or rescission of coverage.

Dental Acknowledgement: I am enrolling myself and/or my dependents and authorize payroll deductions, if applicable. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially falseinformation or conceals for the purposes of misleading, information concerning any fact material thereto may commit a fraudulent act,which is a crime and subjects such person to criminal and civil penalties.

Life/LTD Acknowledgement/Warning:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information inanapplicationforinsurancemaybeguiltyofacrimeandsubjectto fines, confinement in prison and/or denial of insurance benefits. Thiswarningappliestothefollowingstates: Alabama,Alaska,Arkansas,Connecticut,Delaware,Georgia,Hawaii,Idaho,Illinois, Indiana, Iowa, Kansas, Louisiana,Maine,Massachusetts,Michigan,Minnesota,Mississippi,Missouri,Montana,Nebraska,Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas,Utah,Vermont,Virginia,WestVirginia,Wisconsin,Wyoming.

By signing this Application I understand and agree that:

  • IauthorizemyEmployertomakeanyrequireddeductions,ifany,frommysalarytopaythepremiumofmyinsurancecoveragein effect.
  • AllstatementsandanswersIhavegivenarecompleteandtruetothebestofmyknowledgeandbelief.
  • CoverageisnotineffectuntilfinalapprovalisgivenbyMadisonNationalLifeInsuranceCompany,Inc.
  • Noperson,exceptanofficerofMadisonNationalLife,isauthorizedtovaryormodifya life insurance or LTD contract.

X______

SignatureDate

Please return this completed form to Human Resources. Any questions with regards to major group benefits listed within this form can be directed to (651)-407-7548.