(DO NOT STAPLE) Employee Enrollment Form Virgin Islands To speed the enrollment process, please be thorough and fill out all sections that apply. To Be Completed by Employer Group Name ( UnitedHealthcare Requested Effective Date of Coverage/Date of Change / / Policy Number Date of Hire Position/Title Hours Worked per week Salary $ Required only if Life, STD. or LTD Plan based on salary Reason for Application New Group Plan c New Hire Life Event/Date o Annual Status Change Open Dependent Add/Delete Enrollment Change Name/Address O Late Part time to Full time Enrollee Waiving Coverage O Termination Other Employee Type (Check all that apply) Active c COBRA : State Continuation Start dt 1 I End dt / / o Hourly O Salary o Union o Non-Union o Retired Other A. Employee Information Last Name First Name MI Social I Security I Number [— I I I — I I I I Address Apt 4 City State Op Code Home/Cell Phone Date of Birth / / Gender oM o F Marital Status c Single o Married o Divorced O Widowed Work Phone Language Preference, if not English Email Address Do you use tobacco? o Yes o No If yes, are you currently participating in a tobacco cessation program or do you intend to join one? o Yes c No Primary Care Physician' Physician First & Last Name Address Existing Patient? o Yes o No Primary Care Dentist' Dentist First & Last Name ID# ID# — Existing Patient? r Yes III No B. Waiver of Coverage Declining Spouse's Covered COBRA Tri-Care .__ I (vie) o Other coverage due to existence of other coverage: Employer's Plan o Individual Plan by Medicare o Medicaid from Prior Employer El VA Eligibility have no other coverage at this time I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, if applicable, or at the next open enrollment period. I decline all coverage for: Myself c.