FY24 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 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:
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
Dependent 1 Relationship
Dependent 1 - Status (if applicable)
Dependent 1 Add or Delete coverage
Dependent 1 Select Coverages to Add or Delete
Dependent 2 Last name
Dependent 2 First Name
Dependent 2 Date of birth

MonthDayYear
Date
Dependent 2 Gender
Dependent 2 Relationship
Dependent 2- Status (if applicable)
Dependent 2 Add or Delete Coverage
Dependent 2 - Select coverages to Add or Delete
Dependent 3 Last name
Dependent 3 First Name
Dependent 3 Date of birth

MonthDayYear
Date
Dependent 3 - Gender
Dependent 3 Relationship
Dependen 3- Status (if applicable)
Dependent 3 - Add or Delete Coverage
Dependent 3 - Select Coverages to Add or Delete
Dependent 4 Last Name
Dependent 4 First name
Dependent 4 Date of birth

MonthDayYear
Date
Dependent 4 Gender
Dependent 4 Relationship
Dependent 4 Status (if applicable)
Dependent 4 Add or Delete Coverage
Dependent 4 - Select Coverage(s) to Add or Delete
Signature - please sign below if requesting changes
Employee or legal representative signature
Date

MonthDayYear
Date
Should be Empty: