Paperwork - DV New Hire Enrollment Form Principle

Account number/unit number
- Name
- Social security number
- Mailing address (street)
- (city)
- (state)
- (ZIP code)
- MaleFemale
- Birth date
  
  MonthDayYear
  Date
- Date employed full time
  
  MonthDayYear
  Date
- Hours worked per week
- Hours worked per week Job occupation/class
- Job occupation/class
- Location
- Email address
  example@example.com
- Phone Number
  Format: (000) 000-0000.
- YesNo
- MonthlySemi-MonthlyWeeklyBi-Weekly
- Complete if you are electing benefits for your spouse or domestic partner or children.
- Dependent Name
- Birth date
  
  MonthDayYear
  Date
- MaleFemale
- SSN
- SpouseDomestic Partner
- Dependent Name
- Birth date
  
  MonthDayYear
  Date
- MaleFemale
- SSN
- ChildFoster ChildDisabled Child
- Dependent Name
- Birth date
  
  MonthDayYear
  Date
- MaleFemale
- SSN
- ChildFoster ChildDisabled Child
- Dependent Name
- Birth date
  
  MonthDayYear
  Date
- MaleFemale
- SSN
- ChildFoster ChildDisabled Child
- Dependent Name
- Birth date
  
  MonthDayYear
  Date
- MaleFemale
- SSN
- ChildFoster ChildDisabled Child
- YesNo
- **When your child, who is developmentally or physically disabled, reaches/exceeds the maximum age, an Application to Continue Disabled Child form must be completed and reviewed to determine eligibility.
- YesNo
- WARNING: IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY WITH BOTH
  PLANS AT THE SAME TIME. BEFORE YOU ENROLL IN THIS PLAN, READ ALL OF THE RULES VERY CAREFULLY AND COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU OR YOUR FAMILY.
- NOTE: Employee coverage must be elected to elect any dependent coverage.
- ElectDecline
- ElectDecline
- ElectDecline
- YesNo
- NOTE: Employee coverage must be elected to elect any dependent coverage.
- ElectDecline
- ElectDecline
- ElectDecline
- *NOTE: Domestic Partners can only be added if your employer allows this coverage. If enrolling a Domestic Partner,please attach a separate Declaration of Domestic Partnership/Enrollment Form Addendum (GP60472).
- Important! If declining any coverage for yourself or any dependent, give reason. Covered under:
- spouse's or domestic partner's group coverageother coverage offered by my employerindividual insuranceOther
- I understand and agree with the following statements:
  
  • My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and
  any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified
  when a claim is filed.
  
  • If I refuse dental or vision coverage, I and my dependents may enroll later but this will affect the level of benefits.
  
  • If I refuse coverage, I cannot enroll after retirement.
  
  • If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise.
  
  • If the group policy requires my contribution, I authorize my employer to deduct from my pay.
  
  • I represent all information on this form and attachments is complete and true to the best of my knowledge. They are part of this request for coverage. I agree Principal Life is not liable for a claim before the effective date of coverage
  and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During the first two years coverage is in force, fraud or intentional misrepresentations can cause changes in my coverage,
  including cancellation back to the effective date.
  
  • Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud.
  
  • Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I also understand collection of social security numbers for myself and/or my dependents will be used by Principal Life
  only as allowed by law.
  
  • I authorize Principal Life to release data as required by law. If signed in connection with an application, reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for information not yet obtained. I understand data obtained will be used by Principal Life for claims administration and determining eligibility for life, disability, and critical illness. Information will not be used for any purposes prohibited by law.
  
  • I understand that as the employee, the insurance I and my dependents have applied for will begin on the effective date of coverage provided I am at work on that date. If I am not actively at work on such date, subject to the terms
  of the group policy, coverage may not go into effect until after my return to work. Furthermore, I understand that no insurance may become effective for any member of my family while he/she is in a period of limited activity.
  
  A copy of this form will be as valid as the original.
  
  I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from Principal Life Insurance Company.
- Employee Agreement
  
  Clear
- Date
  
  MonthDayYear
  Date
- Should be Empty: