Riverton Industries

Instructions: Use the "TAB" key to move from field to field in this form. Click here to submit a Coverage Declination / Waiver 		Enrollment & Change Form

If you have any questions, please contact
the Human Resources Department.
Email: hrmgr@rivertonindustries.com
Employer's Business Name:
 Business Telephone Number:


New Business Case New Employee
Change (complete name, SS# and any item changing)

Plan Number:

Business Address:
City, State, ZIP:
Section 1. Employee Information
Last Name:
 First Name:
 Middle Name:
Social Security Number:
 Marital Status:
Single Married Widowed Divorced
Home Address:
 City, State, ZIP, Country:
 Home Telephone:
Occupation, Job Title or Position:
 Number of hours worked per week:
 Date of Full-Time employment:
(MM/DD/YYYY)
Are you a
Partner Proprietor Officer 		Annual Earnings:
$ 		 
Dental Insurance if provided:
Yes No 		Life, AD&D Insurance if provided:
Yes No 		Disability Insurance if provided:
Yes No
Beneficiary: If you've selected "Yes" for Life, AD&D Insurance, please provide the following information.
Primary Name:
 Percentage%:
 Relationship:
Contingent Name:
 Percentage%:
 Relationship:
Section 2. Coverage

Health Coverage for:

Employee Only  
Employee and Spouse  
Employee and Child(ren) 
Family

Other (Please specify:)

Click here to submit a Coverage Declination / Waiver
if you are not covering any eligible dependents. 		Does this coverage replace prior coverage?
Yes No

If you've answered "Yes" to coverage replacement, please
provide the following information:
Carrier Name:
Effective Date: (MM/DD/YYYY)
Termination Date: (MM/DD/YYYY)

Do you or your spouse have other group coverage?
Yes No
Carrier Name:
Effective Date: (MM/DD/YYYY)
Termination Date: (MM/DD/YYYY)
Section 3. Change in or Addition of Dependents Coverage

Marriage - Date: (MM/DD/YYYY)
Divorce - Date: (MM/DD/YYYY)
Birth of first child/subsequent children - Date: (MM/DD/YYYY)
Last dependent child reached limiting age - Date: (MM/DD/YYYY)
Other - give reason and date.
"Other" Reason: "Other" Date: (MM/DD/YYYY)

Section 4. Person Proposed for Coverage *
  Name:
(include middle name / maiden name if applicable) 		Social
Security
Number 		Sex Date of Birth
(MM/DD/YYYY) 		State
of Birth 		Height
Feet/Inches 		Weight
Lbs. 		If dependent is
19 or older, is
he/she a
full-time student?
Employee
Spouse Yes No
Child       Yes No
Child       Yes No
Child       Yes No
Child       Yes No
Child       Yes No

* If Spouse has a different last name, provide a copy of your marriage license.
* If Child has a different last name, provide a copy of birth certificate.

Section 5. Enrollment
Last Name, First Name, M.I. Sex
M/F 		Date of
Birth
(MM/DD/YYYY)		 Health Plan Only:
Name of Primary Care
Physician (PCP) or Health Center 		Existing
Patient
Y/N 		Dental Plan Only:
Personal Dentist
Name & Office ID#
Employee:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
OB/GYN (if applicable):
  
  
Spouse:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
OB/GYN (if applicable):
  
  
Child:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
Child:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
Child:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
Child:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:
Child:
  
  
 Physician Name:
  
 Name:
PCP's:
  
 ID#:

Are you or any member of your family applying for coverage eligible for Medicare?
Yes No - If "Yes" please enter the name

Section 6. Signatures

By checking this box I hereby declare that to the best of my knowledge and belief the statements and answers to the questions on this form are complete and true. I understand that if any misstatements or omissions are made on this form, they may be the basis for later recession of the coverage. I understand that if the coverage applied for becomes effective, it will be subject to all the terms of the Group Contract. I am employed by the employer shown on this form, actively at work on a full-time basis, with a normal work week of 30 hours or more. If contributions are required, I authorize my employer to make deductions from my earnings for the cost of participating in my employer's plan. Any person who knowingly and with intent to defraud or deceive any insurer, files a statement of claim or an application containing an false, incomplete or misleading information is guilty of a felony of the third degree.

Authorization: for the Release of Medical Information
To: Any licensed physician; medical practitioner; hospital; clinic or like facility; insurance company; the Medical Information Bureau, Inc.; or other organization; institution or person. I authorize you to give the organization requesting information, any data or records you may have about me or my mental or physical health. This also applies to any dependents named on the application. This authorization is good for two years from the date of enrollment. A photo of this form will be valid as the original.

Type Full Name: Date: (MM/DD/YYYY)
To email this form, you must provide your name and email address in the fields below. If you do not receive a confirmation by email, you probably have not entered your email address correctly. Please allow up to 20 minutes for the message to go through.

Full Name:

Email Address:

Click here to submit data (A confirmation is normally sent when an enrollment form is submitted.
No confirmation will be sent in this demo.)