Addrw/Yf/"Iif te-io? tof kr, I decline all coverage for. Myself 'Spouse Wependent Children Myself and all dependents Employee Enrollment Form Virgin Islands Pi UnitedHealthcare To speed the enrollment process. please be thorough and fill out all sections that apply. m feted by Employer Group Name Oat. of Hire I Requested Effective Dale of Coverage/Date of Chang, / / Pdadidnfrilla execullite a si,:tfan Hours Worked per week Salary $ Required only if Life. STD. or LID Plan based on salary A. Employee Information Last Name Shf I; a k Address /004__ed Noo4 Policy Number Reason for Application New Group Plan Life Event/Date Status Change Dependent AddrDelete Change Name/Address Part time to Full time Waiving Coverage Other • New Hire Annual Open Enrollment Late Enrollee Termination Employee Type (Check all that apply) Active COBRA i State Continuation Stan dt _/_/ End dt / / n Hourly Salary a Union 7, Non-Union a Retied o Other II you are waiving all coverage. please complete sections A and B. Apt Lip Code ociPet Date of Birth Gender I Marital Status f Single remarried O Divorced o Widowed M "IF f Language Preference. if not English Emil Address Prima4 Care Physician' Existing Patient? }es u No Physician First & Larne/2c pTau Plosiermit'zi 2 7:6 7e? e,A, re' 3.3rat Home/Cell Phone Work Phone Do you use tobacco?' n Yes II yes, are you currently participating in a tobacco cessation program or do you intend to pin one? D Yes O No Primary Care Dentist' / Dentist First Last Name pr forrnachiaro ID/ Existing Pa ent? nes r - No Declining coverage due to existence of other coverage. Spouse's Employer's Plan Individual Plan Covered by Medicare Medicaid COBRA from Pnor Employer VA Eligibility Tn-Care I (we) have no other coverage at this lime Other I understand that by waiving coverage at this time, I mil not be allowed to participate unless I qua* at a special enrollment period or as