To submit this form, you can email it to your employer or benefits administrator. Alternatively, you can fax it to the provided number on the form or submit it online via your employer's benefits portal. Physical addresses may also be provided by your employer when submitting in person. Make sure to retain a copy for your records. Verify with your employer for specific submission instructions and deadlines.

Important dates for this form in 2024 and 2025 include the annual open enrollment periods typically held in the fall. Specific dates for 2024 and 2025 may vary, so always check with your employer or UnitedHealthcare for exact timelines.

The purpose of this Enrollment Application/Change/Cancellation Request Form is to allow employees to manage their health insurance benefits with UnitedHealthcare. Whether enrolling for the first time, making changes due to life events such as marriage or birth, or canceling coverage, this form provides the necessary fields and options to ensure accurate processing. Completing this form helps employers ensure employees receive the appropriate benefits and maintain compliance with healthcare policies. It is crucial for maintaining and managing health insurance coverage, providing all the required details to process requests efficiently.

• 1. Employee Information: Includes fields for last name, first name, contact details, social security number, address, date of birth, and more.
• 2. Family Information: Lists details of dependents including their names, relationship, physician details, social security numbers, and birthdates.
• 3. Product Selection: Allows selection of medical, dental, vision, and life insurance options for employees, spouses, and dependents.
• 4. Other Medical Coverage Information: Captures information about other medical insurance plans or policies, including Medicare details if applicable.
• 5. Waiver of Coverage: Provides options for employees to decline coverage and state the reasons for declining.
• 6. Signature: Requires signature of the employee (and spouse if applying for coverage) to confirm accuracy of the provided information.

Failing to submit this form can result in a lapse or delay in health insurance coverage. It can also lead to non-compliance with employer requirements and missed benefits.

• Lapse In Coverage: You may experience a gap in your health insurance coverage, leaving you without protection for medical expenses.
• Non-compliance: Failure to submit the form can result in non-compliance with employer requirements for health benefits.
• Missed Benefits: You may miss out on important health insurance benefits that you or your family are entitled to.

• 1. New Enrollment: Use this form to enroll in health insurance for the first time.
• 2. Changes Due to Life Events: Update your coverage details due to life events such as marriage, birth, or adoption.
• 3. Cancellation of Coverage: Cancel your existing health insurance coverage.
• 4. Adding Dependents: Add new dependents to your health insurance plan.
• 5. Annual Open Enrollment: Make changes to your health insurance coverage during the annual open enrollment period.