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CIGNA Enrollment/Change Form - Georgetown University

CIGNA Enrollment/Change Form - Georgetown University

CIGNA Enrollment/Change Form - Georgetown

Enrollment / Change Form CIGNA InternationalMailing Address: P.O. Box 15050Wilmington, DE 19850Section A - About YouHire Date:Account Number: Employer Name: Coverage Effective Date:Last Name: First Name: Middle Name:Gender: M F Marital Status: Birth Date:Country of assignment:Country of citizenship:Current International Assignment Information (if necessary, please use the reverse side for additional addresses)Address:Street:City:State/Province:Home phone number:Work phone number:Facsimile number:Postal/ZIP code: Country: E-mail address*:AMedicalDentalLTDAnnual Base Salary $*Do you agree to accept the Notice of Privacy Practicesfrom our Privacy Office electronically? Yes NoSection B - Your Benefit ElectionsCoverageTypeMedicalDentalMedicalDentalMedicalDentalPlease List the Name of DependentSection C – Your Dependent Benefit ElectionsRelationship Birth Date GenderFull-timestudent? **Spouse/LDA M F Not ApplicableM F Yes NoM F Yes NoCountry ofResidenceMedicalDentalMedicalDentalM F Yes NoM F Yes No**Please submit proof of full-time student status if dependent child is age 19 or over. If totally disabled prior to age 19, attach proof ofdisability for eligibility review.If You Need to:ADD:DELETE:CHANGE:OTHER:Spouse/LDAAdd Dependent ChildSpouse/LDADependent(s)All CoveragesYour NameYour AddressYour Work LocationSection D - ChangesThen Provide This Information:Date of MarriageDate of Birth / Adoption:Termination Date:Termination Date:ADD COVERAGE: Non-Medical Coverage Dental CoverageFormer Name:SHOW NEW ADDRESS IN SECTION AEffective Date:

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