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International Health Plan Enrollment Form
Please complete this form in you are enrolling in the Alliance International Health Plan. Enrollment is effective on the first day of the month following your hire date. Changes requested after enrolling must be made within 30 days of a qualifying event.
Employee Information
IM Region
*
Field Name
Effective date (please confirm this with your employer)
*
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Employee Last Name
*
Employee First Name
*
MI
Social Security Number
*
Date of Birth
*
+
US Phone
US Email Address
*
Foreign Email Address
*
US Citizen/Citizen Resident:
*
Yes
No
Marital Status:
*
Single
Married
Gender:
*
Male
Female
Spouse Information
Spouse Last Name
Spouse First Name
MI
Social Security Number
Date of Birth
+
US Citizen/Citizen Resident:
Yes
No
Marital Status:
Single
Married
Gender:
Male
Female
Covered Dependent Information
List spouse and/or children to be covered (e
ligible children are those under the age of 26)
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Dependent Full Name (First, MI, Last)
SSN
Birth Date
+
Gender
M
F
Life Insurance
Basic Life Insurance for $30,000 coverage is included in the Health Plan for each employee
Additional Life Insurance may be purchased for the employee, spouse and children (refer to rate chart in summary guide for details)
Up to the maximum amount is guaranteed provided you apply within 30 days of certain eligible events. To begin or increase additional insurance after the 30-day window, you must complete and Evidence of Insurability (EOI) medical history form
Employee Voluntary Life Insurance:
*
🛈
Yes
No
Spouse Voluntary Life Insurance:
*
🛈
Yes
No
Child Voluntary Life Insurance:
*
🛈
Yes
No
If yes, employee amount requested:
If yes, spouse amount requested:
If yes, child amount requested:
Beneficiary Designations
This applies to Life and AD&D Insurance. Designations are not valid unless signed, dated and submitted to Alliance Benefits
Dependent’s insurance, if any, is payable to the employee if living.
Benefits are only payable to secondary beneficiaries if primary beneficiaries are deceased.
If you name two or more beneficiaries:
Two or more surviving beneficiaries will share equally, unless you provide specified unequal shares.
If only one beneficiary survives, we will pay the total death benefit to that beneficiary.
If a minor or your estate is the beneficiary, if may be necessary to have a guardian or legal representative appointed by the court before any death benefit can be paid. If the beneficiary is a trust or trustee, the written trust must be identified in the beneficiary designation.
A power of attorney must grant specified authority by the terms of the document or applicable law to make or change a beneficiary designation. If you have any questions, please consult your legal advisor.
Employee Beneficiaries
Primary Beneficiary Name and Address
SSN
Relationship
%
Primary Beneficiary Name and Address
SSN
Relationship
%
Secondary Beneficiary Name and Address
SSN
Relationship
%
Secondary Beneficiary Name and Address
SSN
Relationship
%
Spouse Beneficiaries
Primary Beneficiary Name and Address
SSN
Relationship
%
Primary Beneficiary Name and Address
SSN
Relationship
%
Secondary Beneficiary Name and Address
SSN
Relationship
%
Secondary Beneficiary Name and Address
SSN
Relationship
%
Declaration and Signatures
I hereby elect coverage under the health plan option for myself and eligible family dependents listed on this form, and I agree that all information provided is correct. I further agree that we shall abide by the selected Plan Document.
I understand that when information changes (e.g. new child, marriage status, leaving employment, or any other change), it is my responsibility to inform Alliance Benefits within 30 days. Failure to provide accurate information or report changes within 30 days may jeopardize my benefits.
I acknowledge that if I do not choose to enroll in Voluntary Life for myself or my dependents within 30 days of my date of hire, transfer, or other specific qualifying event and I choose to enroll in the future, I will be required to satisfy life insurance proof of insurability which will include an Evidence of Insurability medical history form and may require a paramedical exam.
I authorize any physician, medical practitioner, hospital, clinic or other medically related facility, government agency, insurance company, the Medical Information Bureau, or other organization or person that has any records knowledge of me or any family member for whom coverage is requested, to give to Meritain, Express Scripts, or the Alliance Health Plan any such information. A photographic copy of this authorization shall be as valid as the original.
Employees who are not US or Canadian citizens will not be covered by Long Term Disability.
I have read the Privacy Notice made available to me on the Alliance Benefits Website (www.alliancebenefits.org) under the International section.
Employee Signature
*
clear
Signature Date
*
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Spouse Signature
clear
Signature Date
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