Aetna Individual Advantage (SM) for Individuals and Families
Instructions: Send completed enrollment form to:
Enrollment form must be completed by the subscriber in blue or black ink. Please PRINT clearly. Aetna Advantage Dental Plans, U21S
(A photocopy of this enrollment form will not be accepted.) PO Box 730 Blue Bell, PA 19422 Enrollment form must be completed in its entirety and one (1) form of payment selected or
processing time will be delayed. Fax Form to: Individual billing and Enrollment 1-860-975-1253 Signature and date is required.
A. Subscriber Information
Last Name (Last, First, Middle Initial First Name Middle Initial
Address City State ZIP Code
Home Telephone Number (Include Area Code) Cell Phone Number (Include Area Code) Email Address (Optional)
B. Election of Dental Coverage
Aetna Individual Advantage Dental PPO Plan Aetna Individual Advantage Dental PPO Plus Plan
C. Individuals Covered (Complete this section for all persons enrolling for dental coverage, including yourself, spouse and/or family member(s). You may enroll any or all eligible family members.
Family Code* Last Name First Name M.I.
Social Security Number
Date of Birth (MM/DD/YYYY)
Sex (M/F)
APP
SP
DEP 1
DEP 2
DEP 3
D. Effective Date
If Aetna approves my enrollment form, I am requesting an effective date beginning the 1st of the (month).
E. Signature
Applicants Signature Date
PAYMENT OPTIONS
F. Easy Pay (By selecting this option you are approving the automatic withdrawal of your initial premium and all subsequent premium payments.)
Yes, I would like to use Easy Pay.
Checking Account Number:
Routing Number:
Name of Bank:
Name(s) on Checking Account:
No, I do not want to use Easy Pay. Please bill me each month.
Terms of Agreement: My account(s) at the institution named has sufficient funds to pay all debits and charge credits. Aetna shall initiate electronic debit, charge, or credit entries to pay premiums/charges for authorized policies, and the entries are my transaction receipt. There is no payment to Aetna until Aetna receives full and final credit for the payment. I understand that corrections to the entries may involve an account adjustment, and that my direct electronic payment of Aetna's premium will be debited/charged on or after the premium due date each month. No bill will be issued. I understand that by checking the "Yes" box above and with my enrollment form signature on Page 1, Section E, I am accepting the terms of the Easy Pay Agreement.
Any rate adjustment made in accordance with the underwriting process will be automatically charged to your account.
NOTE: The initial premium payment will be deducted upon approval of your enrollment form. Aetna reserves the right to refuse/terminate electronic payment services at any time. This agreement remains in effect until Aetna/member terminates it. Joint accounts require the signature of ALL account authorized persons (Page 1, Section E) even if not applying.
GR-68453 (11-16) 1
PAYMENT OPTIONS (continued)
G. Credit Card Payment Option
Credit Card Type
Visa MasterCard
Cardholder's Name (exactly as it appears on the card)
Account Number Card Expiration Date Card Verification Code*
- - -
Credit card payment is for your initial premium payment only and will be charged upon approval of your enrollment form. You will receive a bill on your next billing statement.
Any rate adjustment made in accordance with the underwriting process will be automatically charged to your account.
*The Verification Code can be found on the back of your credit card. This 3-digit code is usually the last three digits located in the signature panel.
H. Payment by Personal Check or Money Order
Please include a personal check or money order made payable to Aetna and attach to your completed enrollment form.
I. Insurance Producer Attestation To be completed by Insurance Producer/Broker of Record
Producer who met with customer
1. Did you see the proposed applicant (and spouse/domestic partner, if applying) at the time this application was executed? If No, please explain.
Yes No
2. To the best of your knowledge, is the information on this application complete and accurate? If No, please explain. Yes No
3. You have explained in easy to understand English (or via translation where applicable) the risk to the applicant of providing inaccurate information on this application, and that the applicant fully understands your explanation.
Yes No
4. Did the primary applicant complete this application and review prior to signing? If No, please explain. Yes No
Signature of Producer who met with customer (Required if applicable) Print Name
TIN of Signing Producer Alternative ID (NPN number)
Email Address Telephone Number
( )
Fax Number
( )
Signature of Signing Agent (supports the broker of record) (Required if applicable)
Print Name of Agent NPN number
Signature of Agency Representative (Broker of Record) Print Name of Agency Representative
TIN of Agency to be assigned as Broker of Record Alternative ID (NPN number)
Email Address Telephone Number
( )
Fax Number
( )
Street Address (Street, Suite No./Personal Mail Box (PMB) No./City/State/ZIP Code)
Name of General Agent (Required if applicable) TIN of General Agent
Street Address (Street, Suite No./Personal Mail Box (PMB) No./City/State/ZIP Code)
J. Aetna Sales Representative
Last Name of Agent (Print Name) First Name of Agent (Print Name) License Number
K. Authorization
I have read the information contain in this application and choose to enroll. I understand that my enrollment is subject to receipt of payment and verification of funds. Eligibility will begin on the first day of the month following receipt of the enrollment form. I understand that the Electronic Funds Transfer (EFT) for the monthly premium payment will be automatically deducted from my bank account.
I hereby certify that the information contained in this application is true and complete.
Applicants Signature Date
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Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call (855) 208-4606.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and
their affiliates (Aetna).
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:[email protected]
TTY: 711
For language assistance in English call 855.208.4606 at no cost. (English)
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*
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