Important Information

NEW FOR 2008: You must work a minimum of 750 hours per year to be eligible for this program.

EMPLOYER POLICIES: Please note that each congregation or employer may have its own policy regarding participation in the UUA Health Plan. Refer to the UUA Health Plan Subscription Agreement on file with your employer, or contact the Health Plan at (617) 948-4265 or kmacdonald@uua.org for more information.

Please review the following information and have the below employee and dependent information before you start the enrollment process.

Once you start the Enrollment process you will not be able to stop and save your information. You must complete the Enrollment Process in its entirety for your information to be submitted. If you close the web browser in the middle of the Enrollment Process you will have to start over.

After each step you will have the chance to review and edit your information. You will also have the opportunity to review your information at the end of the Enrollment Process.

You will see a red star reminder (*) next to fields that are required or have been entered incorrectly.

Your Social Security Number is encrypted; all information is confidential and stored in a secure location.

If you have any questions please contact Kati MacDonald at (617) 948-4265 or kmacdonald@uua.org

Information for Employees

Section 1: Health Insurance Plan

Section 2: Residential Contact Information

Section 3: Employment Information

Section 4: Biographic Information

Information for Dependents

Who is a Dependent

Add a Dependent to Existing Coverage

Section 1: Dependent Information

Information for Medicare (if you are enrolling in the UUA Medicare Supplement Plan)

Section 1: Medicare Information

Information for Supplemental Insurance (if you are keeping other coverage in force)

Section 1: Supplemental Insurance Information

Section 1: Health Insurance Plan

1. Insurance Plan:

• Standard PPO
• High Deductible – HSA Eligible
• High Deductible – Not HSA Eligible
• Medicare Supplement

2. Coverage Type:

• Employee Only
• Employee + Spouse or Partner
• Employee + Child or Children, Family
• Family

3. Number of Dependents

4. Reason for Application:

• 2008 Enrollment
• New Hire
• Rehire
• Increase in Hours
• Add a new Dependent
• Other Qualifying Event

4a. Explain Other Qualifying Event or the addition of a new dependent; for example: marriage, birth, adoption, loss of other coverage.

5. Effective Date of Coverage, confirm with your administrator

6. Congregation/ association ID, 'RETD' if you are retired or 'SELF' if you are self employed. Contact Kati MacDonald for all other employment situations.

7. Employee Social Security Number

8. Employee First and Last Name

8a. Middle Initial and Suffix (optional)

Section 2: Contact Information

1. Home Address

2. Home Phone Number

2a. Work Phone Number (optional)

3. Email Address

Section 3: Employment Information

1. Employment Status:

• Active
• Retired

2. Congregation or Place of Employment

3. Hire Date

4. Hours Worked Per Year. You must work a minimum of 750 hours per year to be eligible for enrollment.

5. Job Description

5a. Other Then On List

6. Retired Date (if applicable)

Authorizing Church Leader:(the officer, administrator, or other person certifying your employment and hours worked)

7. Certifier's Name

8. Certifier's Phone Number

9. Certifiers' Email Address

Section 4: Biographic Information

1. Date of Birth

2. Gender

3. Are you Disabled and unable to work?

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Dependent Information

Who is a Dependent

Dependents include: Spouse or domestic partner, children/stepchildren to age 19, (full-time students to age 25)

Add a Dependent to Existing Coverage

To add a dependent to your existing coverage please use this form: New Dependent Enrollment

Note: You will need to fill out this form for each Dependent you enroll.

Section 1: Dependent Information

1. Dependent First and Last Name

2a. Middle and Suffix (if applicable)

3. Dependent Social Security Number, select the Pending box if the dependent is awaiting their Social Security Number

4. Relation Code:

• Spouse
• Domestic Partner
• Child

5. Dependent Date of Birth

6. Dependent Gender

7. Is the Dependent a Student 19 and Over?

8. Is the Dependent Disabled?

Annual documentation of student status and/ or disability status will be required.

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Medicare Information

Complete this section ONLY if you are enrolling in the UUA Medicare Supplement Plan.

Section 1: Medicare Information

1. Medicare Number

2. Part A Effective Date

3. Part B Effective Date

4. Part D Effective Date

5. Why are you eligible for Medicare:

• Age
• Disability
• End Stage Renal Disease

6. Will you keep another Medicare Supplement or other coverage that complements Medicare?

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This information applies ONLY to coverage that you will have in force IN ADDITION TO your UUA coverage.

Section 1: Supplemental Insurance

1. Name of Carrier

2. Group Number

3. Policy Number

4. Effective Date

5. Relationship

• Self
• Dependent

6. Policy Date

7. Employment Status

• Active
• Retired
• Not Employed

7a. Retired Date (if applicable)

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