Insurance Enrollment GROUP NAME: Baart Industrial Group | GROUP #: P34 "*" indicates required fields Personal InformationName* First Middle Last Employee SSN* Date of Birth* Male / Female Male Female Marital Status* Single Married Divorced Other Hours Worked Per WeekEmail* Phone* Address* Street Address Apt/Unit # 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 Coverage ElectionMedical (choose one) Single Employee + Spouse Employee + Child(ren) Family Dental (choose one) Single Employee + Spouse Employee + Child(ren) Family Waive Coverage I WAIVE ALL MEDICAL COVERAGE — Please sign below Dependents (enrolling in plan)SPOUSEName* First Middle Initial Last Male / Female* Male Female Birth Date* SSN* Other Insurance ?* Yes No CHILD 1Name* First Middle Initial Last Male / Female* Male Female Birth Date* SSN* Other Insurance ?* Yes No CHILD 2Name First Middle Initial Last Male / Female Male Female Birth Date SSN Other Insurance ? Yes No CHILD 3Name First Middle Initial Last Male / Female Male Female Birth Date SSN Other Insurance ? Yes No Other Coverage InformationThis section must also be filled out for anyone having other coverage, including Medicare coverage OTHER INSURED 1Name of Covered Person* Effective Date* Carrier Name* Name of Policy Holder* OTHER INSURED 2Name of Covered Person Effective Date Carrier Name Name of Policy Holder OTHER INSURED 3Name of Covered Person Effective Date Carrier Name Name of Policy Holder Sign(1) I am enrolling for the benefits indicated in the “Coverage Election” section. If required, I authorize deductions from my earnings. (2) By completing the “Waiver of Coverage”, I understand I am refusing coverage and that there may be penalties if I decide to reapply at a later date. (3) I hereby authorize any licensed physician, hospital, clinic, or other medical or medically related facility, insurance company, the Medical information Bureau, or other organization, institution, or person, that has any records or knowledge of me and/or my dependents’ health, to give to Lucent Health Company or the reinsurer any such information. (4) I also authorize Lucent Health or the reinsurer to release any information regarding me and/or my dependents to the Medical Information Bureau and to other carriers through which I have policies or to whom I may apply or to whom a claim for benefits may be submitted. (5) I hereby certify that all the information shown above is true and correct to the best of my knowledge. I also understand that any false information listed will nullify this application and the coverage for which I am applying. Lucent Health Company has the right to rescind coverage should the above information prove to be not complete or accurate.Employee Signature*Today's Date* EmailThis field is for validation purposes and should be left unchanged.
