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Scout 5 Group Health Employee Enrollment Form
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
SSN
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Male/Female
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who is covered for health (select one)
*
Employee Only
Employee/Spouse
Employee/Children
Family
I am not applying for Health Coverage
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EMPLOYEE/SPOUSE
Husband/Wife Name
Husband/Wife
Husband
Wife
Husband/Wife SSN
Husband/Wife Birthday
-
Month
-
Day
Year
Date
Husband/Wife Address ONLY IF DIFFERENT
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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EMPLOYEE/CHILDREN
Dependent 1 Name
Dependent 1
Son
Daughter
Other Eligible Dependent
Dependent 1 SSN
Dependent 1 DOB
-
Month
-
Day
Year
Date
Choose one
This dependent is a natural child, stepchild, foster child, adopted child, or a child in suit for adoption
If not your eligible natural child, stepchild, foster child, adopted child or child in suit for adoption, you are (or your spouse) responsible for this dependendent.
Dependent 1 Address ONLY IF DIFFERENT
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dependent 2 Name
Dependent 2
Son
Daughter
Other Eligible Dependent
Dependent 2 SSN
Dependent 2 DOB
-
Month
-
Day
Year
Date
Choose one
This dependent is a natural child, stepchild, foster child, adopted child, or a child in suit for adoption
If not your eligible natural child, stepchild, foster child, adopted child or child in suit for adoption, you are (or your spouse) responsible for this dependendent.
Dependent 2 Address ONLY IF DIFFERENT
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dependent 3 Name
Dependent 3
Son
Daughter
Other Eligible Dependent
Dependent 3 SSN
Dependent 3 DOB
-
Month
-
Day
Year
Date
Choose one
This dependent is a natural child, stepchild, foster child, adopted child, or a child in suit for adoption
If not your eligible natural child, stepchild, foster child, adopted child or child in suit for adoption, you are (or your spouse) responsible for this dependendent.
Dependent 3 Address ONLY IF DIFFERENT
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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TYPE NAME AGAIN
Declination of Coverage (SKIP THIS UNLESS YOU ARE DECLINING THIS POLICY)
Why are you declining coverage?
Other Group Health
Other Individual Health
I am not enrolled in a health insurance plan and do not want this coverage.
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Signature
*
Continue
Continue
Should be Empty: