800-310-6645
Electronic Enrollment Change Form

INSTRUCTIONS: This form should be used for a new enrollment, termination of an employee, waiver (decline) of coverage, enrollment of a terminated employee in COBRA, or adding or deleting a dependent. Please complete all information and sign your name on the "Employee's Signature:" line. An "On-Time Enrollment" is within 31 days of your eligibility date. A "Late Enrollment" is after the thirty-one day period has expired; however, a "Special Enrollment" occurs if a person is enrolling late because they have lost other health insurance coverage through no fault of their own. To qualify for a "Special Enrollment", the enrollment must occur within 31 days of the date of the loss of the other coverage.


Requested action (for new enrollments, the type of enrollment may affect the length of the pre-existing limitation period):

New "On-Time"
Enrollment

    New "Late"
Enrollment
    New "Special"
Enrollment
    "COBRA" Enrollment

Waive Coverage
(See Bottom)

    Termination     Delete Dependent     Add Dependent

If you have not been enrolled on the current plan for twelve consecutive months, there may be a pre-existing coverage exclusion for claims that are for a pre-existing condition(s). This period can be reduced by prior health insurance coverage if you were covered within 63 days from the date the prior coverage terminated to your hire date. If you had coverage within the 63 day time frame, you should have a certificate from the previous plan that verifies the coverage.

1) Will you be enrolled for twelve consecutive months as of this Plan's effective date?
     If No, answer #2 and read and sign reverse side.
2) If No, did you have coverage within the 63 day period?
3) If Yes, is certificate attached?
     If No, read and sign reverse side.

EMPLOYEE INFORMATION
Full Name
Last Name

First Name

Middle Name
Birth Date       Age: Sex:
Social Security Number: --
Effective Date On Current Plan:
  
Effective Date On This Plan:
  

Residence:

Address:
Additional
Address:
City: State: Zip Code:

Employer:

Company Name:
City: State: Zip Code:
Employee Occupation: Life Ins. Amount:
Not Necessary
Hours Worked Per Week:  Date of Hire:  
Employee Work Phone: () -  Ext: 
Is your spouse employed?  Company Name: 
Are you or any of your
dependents covered by
other health insurance:


If yes...
Carrier Name:
Address:
City:  State:    Zip/Postal Code:

COVERAGE INFORMATION
Select type of coverage desired:  
     Single   Family    
     
Employee plus dependents
COBRA RIGHTS: Upon enrolling in this Plan, you have COBRA continuation rights should your coverage terminate. You will receive a Summary Plan Description that includes an explanation of your COBRA rights. Please review the COBRA section.

DEPENDENTS TO BE COVERED FOR MEDICAL & DENTAL (If Offered)

Effective date of this action: 
1 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

2 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

3 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

4 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

5 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

6 Name: 
                    
First & Last Name
Relationship: 
Date of Birth: S S N: -- 
Age: Sex:   Student:

LIFE INSURANCE and AD&D BENEFICIARY INFORMATION
(Complete if these benefits are offered.)
Primary
Name: 
          First & Last Name
Relationship: 
Date of Birth:  

Secondary
Name: 
          First & Last Name
Relationship: 
Date of Birth:  

Please check only one of the following four options and "sign" this submission in the Authorization area below.
Please answer the other questions in the section where you check.

Terminated Employee (and dependents):

1) COBRA Enroll I hereby understand my COBRA rights and elect to enroll...
...for myself only.
...for my dependents only.
...for myself and my dependents.

2) COBRA Decline

I hereby understand my COBRA rights and elect to decline coverage under COBRA...
...for myself only.
...for my dependents only (each dependent may have a separate COBRA right).
...for myself and my dependents (each dependent may have a separate COBRA right).

Active Employee:

3) Active Enroll

I hereby enroll for coverages as checked above for which I am eligible.

I authorize my employer to deduct my contributions, if any, from my earnings.

I authorize any person or organization having records or knowledge of me or my family, or of our health, to give Avalon Benefit Services, Inc. or its legal representative, licensed physicians or practitioners, hospitals, clinics or medically related facilities, insurance companies and others who have a legimate need for such information for the purpose of review, investigation or evaluation.

I agree that a photo copy of this authorization shall be valid as the original.

I understand and agree that benefits payable for any pre-existing condition(s) may be limited unless reduced by certification of prior coverage.

I understand that failure to comply with the pre-certification or other Cost Management procedures of the Plan may result in a reduction of benefits.

I hereby certify that the information given above is true and complete to the best of my knowledge.

I understand that any misstatements, omissions or misrepresentations may result in the rescission of any insurance coverage issued in connection with the Employee Benefit Plan.
4) Active Decline



If declining coverage, answer these three questions.
I hereby decline or refuse the coverage indicated below and acknowledge that, if I later decide to participate, pre-existing payment limitations may apply.

    I decline coverage for Myself

    I decline coverage for My Dependents 

    I have coverage elsewhere?


AUTHORIZATION

By entering my name (as listed above) in the "Employee Signature" space below, checking the "AGREE" button and pressing the "Submit Form" button, I hereby authorize the processing of this internet form submission with the same legality as if my actual signature appeared.

I (AGREE / DISAGREE ) with this statement.

Employee Signature:   


Avalon Benefit Services, Inc.   P.O.Box 1803   Dublin, OH 43017

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6543 Commerce Parkway, Suite M, Dublin, OH 43017
Phone: 800-310-6645    Fax: 844-328-5824