UUA Health Insurance Enrollment Application

Please review and gather the required information for the Enrollment Process:

Required Information

You will see a red star reminder (*) next to fields that need to be entered or have been entered incorrectly.

Your Social Security Number is encrypted; all information is confidential and stored in a secure location.

You will receive an email confirmation when you finish your application.

To add a dependent to your existing coverage please use this form

If you have any questions please contact Insurance Plans at (888)792-7496 or InsurancePlans@uua.org

Reason for Application*

Reason for adding dependent(s)

Qualifying Event

Please upload proof of loss coverage

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Congregation ID*

To begin the enrollment process please enter an identifier in the box below: Your 4-digit congregation ID or association ID. (Select ID Here.)

For community ministers and retirees, enter SELF.

If you do not see your congregation or association ID code on the list, please contact Insurance Plans at (888) 792-7496 or insuranceplans@uua.org for the correct code.

UUA Health Plan*

Select a coverage tier that’s consistent with your employer’s subscription agreement and, if any, your employment contract.

Guardian Group Insurance Plans*

Coverage Type*

Number of Dependents

If you elected to enroll dependents into a Group Insurance Plan(s) will there be different dependent elections?

YesNoN/A

If yes, which Group Insurance Plans will have different benefit elections?

Thank you for clarifying and be sure to upload the e-forms to specify your dependent elections.

Please add any additional note to help with the processing with your application

Guardian Group Insurance Plans Application

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Attach application

Guardian Group Insurance Plan Enrollment Form

Employee's Name*

First NameLast Name

Employee's Date of Birth*

Date

Employee's Social Security Number*

Dashes Not Required

Employee's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employee's Phone Number*

Employee's Email*

example@example.com

Employment Status*

Hire Date*

Date

Benefit Effective Date*

Effective date must be within 60 days of hire or within 30 days of a qualifying event

Annual Salary*

Annual salary includes housing supplement if applicable

Retired Date

Date

Hours worked per year*

You must work a minimum of 750 hours per year to be eligible for enrollment unless retired.

Job Function*

Certifier's Name

First NameLast Name

Certifier's Job Description

Certifier's Phone Number

Certifier's Email

example@example.com

UUA Insurance Plans Benefit Enrollment

Section One

Section Two

Section Three

Authorizing Church Leader or Administrator

Dependent Demographics