Insurance Enrollment GROUP NAME: Baart Industrial Group | GROUP #: 76417127 "*" indicates required fields Employee InformationName* First Middle Initial Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number (SSN)If you do not have a SSN, please enter an alternate ID number.Alternate ID NumberDate of Birth*Gender* Male Female Marital Status* Single Married Divorced Other Additional InsuranceDo you or any family member currently have other health coverage?* Yes, Single Yes, Family No Name* First Last Employer*Carrier Name*Plan Number*Do you or any family member currently have other dental coverage?* Yes, Single Yes, Family No Name* First Last Employer*Carrier Name*Plan Number*Coverage ElectionsUMR Medical* Employee Employee + Spouse Employee + Child(ren) Family Waive Coverage UMR Dental* Employee Employee + Spouse Employee + Child(ren) Family Waive Coverage DependentsSPOUSEName* First Middle Initial Last Gender* Male Female SSN*Date of Birth*CHILD 1Name* First Middle Initial Last Gender* Male Female SSN*Date of Birth*CHILD 2Name First Middle Initial Last Gender Male Female SSNDate of BirthCHILD 3Name First Middle Initial Last Gender Male Female SSNDate of BirthCHILD 4Name First Middle Initial Last Gender Male Female SSNDate of BirthCHILD 5Name First Middle Initial Last Gender Male Female SSNDate of BirthWaiving CoverageImportant: If you decline benefits for yourself or your dependents, you may in the future be able to enroll yourself or your dependents in this benefit plan. You may have an opportunity to enroll during your annual enrollment period or if your family status changes. If you decline benefits because of other group health or insurance coverage, and state so in writing, you may have the opportunity to enroll under HIPAA Special Enrollment because of loss of that coverage. By checking the box below, you are attesting that you are declining enrollment in this plan because you are enrolled in other group health coverage: Waive Confirmation* I attest that I am declining group health coverage because I am currently enrolled in other group health or insurance coverage. For specific plan language contact your Human Resources Representative CERTIFICATION: I freely and voluntarily waive all coverage noted above. Signature*Date*ConfirmationI hereby certify that all of the above information is true and correct. I understand that coverage will not be effective until all questions regarding eligibility for coverage have been satisfactorily resolved. I understand that I may not change the coverage elections that I make on the Employee Enrollment/Change Form until the plan’s next open/annual enrollment period or unless otherwise permitted by the Plan. Please refer to your Employee Benefit Booklet for specific detail of your benefit plan.Enroll Confirmation* I hereby apply for coverage and authorize deductions from my earnings for the amount required, if any, to cover any contribution for coverage. SignatureDate
