Group Medical Insurance - University of Hartford

Group Medical Insurance - University of Hartford

2012 OPEN ENROLLMENT REQUEST FORM
REGULAR PART-TIME FACULTY AND STAFF
Name
Department
YOU ARE CURRENTLY ENROLLED IN THE FOLLOWING BENEFIT PLANS:
Medical Insurance:
Dental Insurance:
Life Insurance:
GROUP MEDICAL INSURANCE ELECTION – United HealthCare
STEP 1: Confirm your medical insurance coverage election for 2012.

Core Point of Service (POS) Plan

Enhanced Point of Service (POS) Plan
Note: If you are electing to enroll, change plans or terminate coverage, an additional form is required to
process this change.
 I do not wish to participate in a University of Hartford medical insurance plan at this time. I am aware
that if I elect to enroll in the group medical insurance plan after the open enrollment period, I may be subject to
proof of insurability at my own expense, or will have to wait for a qualifying event or future enrollment period.
STEP 2: Confirm who will be covered under your medical insurance plan.
 Employee only
 Employee + spouse/same-sex partner
 Employee + child(ren)
 Employee + spouse/same-sex partner + child(ren)
Note: If you are electing to add or drop dependents, an additional form is required to process this change.
STEP 3: If you are interested in taking advantage of the PureWellness program * and the corresponding
discount to your medical insurance premium, please indicate the adults under your group medical insurance that
will enroll in this wellness program (excluding children of any age):
 Employee Only
 Spouse/Same-sex Partner Only
 Both employee and spouse/same-sex partner
* If you (and/or your spouse/same-sex partner) are electing to participate, an additional form is required. *
 I do not wish to participate in the PureWellness program at this time. I am aware that quarterly
enrollment periods will be offered and I can enroll in the PureWellness program during these enrollment periods.
GROUP DENTAL INSURANCE ELECTION – Aetna Freedom of Choice Plan
Confirm your dental insurance coverage election for 2012.
 Employee only
 Employee + spouse/same-sex partner
 Employee + child(ren)
 Employee + spouse/same-sex partner + child(ren)
If you are electing to enroll, add or drop dependents or terminate coverage, an additional form is required to
process this change.

I do not wish to participate in the Aetna Freedom of Choice dental insurance plan at this time.
OPTIONAL LIFE INSURANCE(S)
Supplemental Life Insurance (Please check one box below)
 I do not wish to purchase
 Continue current
 Enroll *
supplemental life
supplemental life
insurance at this time
insurance benefit
election.

Make
changes *
Spousal /Same-Sex Partner Life Insurance (Please check one box below)
 I do not wish to purchase
 Continue current
 Enroll *
 Make
spousal/same-sex partner
spousal/same sex
changes *
life insurance at this time
partner life
insurance benefit
election
Dependent Child(ren) Life Insurance (Please check one box below)
 I do not wish to purchase
 Continue current
 Enroll *
 Make
dependent child(ren) life
dependent
changes *
insurance at this time
child(ren) life
insurance benefit
election
Personal Accident Insurance (Please check one box below)
 I do not wish to purchase
 Continue current
 Enroll *
personal accident
personal accident
insurance at this time
insurance benefit
election

Make
changes *

Drop current
supplemental life
insurance benefit
election *

Drop current
spousal/same-sex
partner life
insurance benefit
election *

Drop current
dependent
child(ren) life
insurance benefit
election *

Drop current
personal accident
insurance benefit
election *
* An additional form is required to process this change.
All enrollment forms are available on the HRD website at www.hartford.edu/hrd. All forms must be returned to HRD no later
than Friday, October 28, 2011. All elections become effective January 1, 2012.
AUTHORIZATION AND RELEASE
I authorize the University of Hartford to enroll me in the benefits I have elected. I agree to make the necessary
premium payments for all elected coverage. I will submit all payments directly to the Bursar’s Office on a monthly
basis for as long as I am enrolled in the plan(s).
My signature below indicates that I have read and understand this election form and descriptive material provided.
The election(s) I select are binding for one year and cannot be revoked or modified except under limited
circumstances (qualifying events) as defined by IRS regulations.
I declare that the dependents enrolled are my eligible dependents. I declare that the information furnished on this
form is true, correct and complete to the best of my knowledge.
_______________________________
Signature
To be completed by HRD:
___________
Phone Ext.
[email protected]
Email
___ Enrollment form(s) processed
___ Deduction status verified
_____ Initials
_____ Date
___________
Date