Humana Employee Change Form GN-99955-CG-0309

Please print clearly and fill in each applicable circle.
Proposed Effective Date for change

MonthDayYear
Date
Company name
Company city
Employee Information and Changes

Please provide employee information and indicate all applicable employee changes.
Employee Name*

First nameLast name
Select Medical Coverage or Waive*
Select Medical Coverage Group
Select Dental Coverage or Waive*
Select Dental Coverage Group
Life Insurance Primary beneficiary Last name*
Life Insurance Primary Beneficiary First name*
Life Insurance Secondary beneficiary Last name
Life Insurance Secondary Beneficiary First name
Vision Coverage or Waive*
Select Vision Coverage Group
Cancel My Coverage for the following:

MedicalDentalVision
Please complete this section for all dependent changes.
Dependent 1 Last Name
Dependent 1 First Name
Dependent 1 Date of birth

MonthDayYear
Date
Dependent 1 Gender

FemaleMale
Dependent 1 Relationship

SpouseChildOther
Dependent 1 - Status (if applicable)

Full-time studentDisabled
Dependent 1 Add or Delete coverage

AddDelete
Dependent 1 Select Coverages to Add or Delete

MedicalDentalVision
Dependent 2 Last name
Dependent 2 First Name
Dependent 2 Date of birth

MonthDayYear
Date
Dependent 2 Gender

FemaleMale
Dependent 2 Relationship

SpouseChildOther
Dependent 2- Status (if applicable)

Full-time studentDisabled
Dependent 2 Add or Delete Coverage

AddDelete
Dependent 2 - Select coverages to Add or Delete

MedicalDentalVision
Dependent 3 Last name
Dependent 3 First Name
Dependent 3 Date of birth

MonthDayYear
Date
Dependent 3 - Gender

FemaleMale
Dependent 3 Relationship

SpouseChildOther
Dependen 3- Status (if applicable)

Full-time studentDisabled
Dependent 3 - Add or Delete Coverage

AddDelete
Dependent 3 - Select Coverages to Add or Delete

MedicalDentalVision
Dependent 4 Last Name
Dependent 4 First name
Dependent 4 Date of birth

MonthDayYear
Date
Dependent 4 Gender

FemaleMale
Dependent 4 Relationship

SpouseChildOther:
Dependent 4 Status (if applicable)

Full-time studentDisabled
Dependent 4 Add or Delete Coverage

AddDelete
Dependent 4 - Select Coverage(s) to Add or Delete

MedicalDentalVision
Signature - please sign below if requesting changes
Employee or legal representative signature

Clear
Date

MonthDayYear
Date
Should be Empty: