Sharp Honda Enrollment Form

Name of Employer *

Name *

First Name Middle Name Last Name

Social Security Number *

123456789

Date of Birth *

MMDDYYYY

Gender *

Male Female

Marital Status *

Single Married Divorced/Separated Widowed

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Date of Full Time Employment *

Eligibility or Start Date *

Do you or any dependents covered on the plan use tobacco products? *

Yes No

If yes, please mark all that utilize tobacco products

Self Spouse Child Child

Are you and all eligible dependents vaccinated against COVID-19? *

Yes No

If no, please indicate which members are not vaccinated

Self Spouse Child Child

Coverage You are Enrolling In *

Single Employee/Spouse Employee/Child(ren) Family Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.

Health Plan Option *

Plan A ($500 deductible) Plan B ($1,200 deductible) Plan C ($1,500 deductible) Plan D ( $4,500 deductible) Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.

Covered Dependents (if single coverage put NONE in spouse name) *

	Name	Social Security #	Date of Birth	Gender
Spouse
Child
Child
Child
Child
Child
Child
Child
Child

Will you and/or a member of your family have any other health insurance in addition to the Sharp Honda Health Plan? *

No Yes

Do you and/or a member of your family have Medicare coverage? *

No Yes

AUTHORIZATION: I hereby authorize any physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution or person that has any records or knowledge of me or my dependents or my health to give to the Plan Administrator any such information. A photographic copy of this authorization shall be as valid as the original. I understand by enrolling in the Plan I am agreeing to a one year commitment and cannot terminate until the Plan renewal. *

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