Enrollment /Change of Status Form

EMPLOYEE INFORMATION
Full Name*

First NameM.I.Last Name
NetCare Member #
Social Security #*
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Marital Status*
Home/Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Other Contact Number
Please enter a valid phone number.
Email Address*
example@example.com
Please click here if you do not have an email address
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Occupation*
Date of Hire*

MonthDayYear
Date
Requested Effective Date

MonthDayYear
Date

Beneficiary Information
Beneficiary's Full Name*
Relationship to Subscriber*
Date of Birth*

MonthDayYear
Date

Acknowledgement
I agree that I (we) shall abide by the provisions of coverage in the policy under which I (we) are enrolled. I understand that it is my responsibility to report any changes in the eligibility of my dependents. I understand that any claims asserted by myself or my dependents against NetCare Life & Health Insurance company or any provider, whether based in tort, contract or otherwise (including profession liability) are subject to binding arbitration. I have read the benefit brochure and any questions pertaining to the NetCare Health Plan has been answered satisfactorily. I (we) hereby authorize my employer to deduct any required costs for the program from my wage. I have had the opportunity to review the group comprehensive medical expense insurance policy issued to the employer, and agree that I (we) will be bound by the terms and conditions therein contained.

Fraud Warning Notice: Any person with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits a request for enrollment, or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Employee Signature*

Clear
Date*

MonthDayYear
Date
Employer Signature

Clear
Date

MonthDayYear
Date
Should be Empty: