Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
Retiree Group Health & Life insurance Enrollment Application
Part I: Please print or type
Part II: Complete items in this part to indicate action requested
Name: _____________________________________________________ Address: ___________________________________________________ City: ________________________ State: _____ Zip Code: ___________ Sex:  Male  Female Married:  Yes  No
Birth Date: ________________________ SSN: _____________________________ Email: ____________________________ Daytime Tel #: ______________________
ACTION REQUESTED
 New Enrollment
 Change Enrollment
For Retiree:
Are you eligible for Medicare Parts A & B?
Have you applied for Medicare Parts A & B?  Yes  No Part B (Medical) Effective Date: _______________________ Medicare Claim Number: ______________________________
Do you have other coverage?  Yes  No If yes, name of carrier: ____________________________________________
 Cancel my enrollment
 Cancel Spouse – Explanation: ________________________________________
 Yes  No Part A (Hospital) Effective Date: _______________________
HMSA HEALTH PLAN HAWAII – BASIC
For Ages 591⁄2-64  Self
 2-Party
 Check here if you do NOT want the drug rider
HMSA HEALTH PLAN HAWAII PLUS
For Ages 591⁄2-64  Self
 2-Party
 Check here if you do NOT want the drug rider
HMSA PARTICIPATING
PROVIDER
For Ages 591⁄2-64  Self
 2-Party
 Check here if you do NOT want the drug rider
HMSA COMPREHENSIVE MEDICAL
For Ages 591⁄2-64  Self
 2-Party
 Check here if you do NOT want the drug rider
KAISER PLAN B
For Ages 591⁄2-64  Self
 2-Party
 Check here if you do NOT want the drug rider
HMSA AKAMAI ADVANTAGE PLAN
For Ages 65 and Over
**Please also complete Akamai Advantage Enrollment Form.  Self  2-Party
 Check here if you do NOT want the RCUH drug rider
**If you do not elect the RCUH drug rider, please provide us with a copy of your current drug coverage member ID card to verify coverage is acceptable with the HMSA Akamai Advantage Plan.
KAISER SENIOR ADVANTAGE PLAN
For Ages 65 and Over
 Self  2-Party
 Check here if you do NOT want the RCUH drug rider
FOR RETIREES ENROLLED IN HMSA – HEALTH PLAN HAWAII or HEALTH PLAN HAWAII PLUS, YOU MUST NAME A PRIMARY CARE PHYSICIAN AND HEALTH CENTER FOR YOURSELF AND YOUR SPOUSE.
For Retiree: Primary Care Physician: _________________________________ Health Center: _______________________ For Spouse: Primary Care Physician: _________________________________ Health Center: _______________________
RCUH Form B-27
Created 06/2008, (Revised 11/2010, 02/2012, 07/18/2014, 3/30/2016)
RE: Retiree Group Health & Life Insurance Enrollment Application Page 2 of 2
Part III: Dependent Information
Spouse: __________________________________________________________________________________________________
Last First Spouse’s Date of Birth: _____________________________
Is your Spouse eligible for Medicare Parts A & B?  Yes
Has your Spouse applied for Medicare Parts A & B?  Yes
Spouse’s Medicare Claim Number: ________________________ Explanation: _________________________________________ Does your spouse have other coverage?  Yes  No If yes, name of carrier: _____________________________________
Initial
Spouse’s SSN: ___________________________________________
 No Part A (Hospital) Effective Date: ____________________  No Part B (Medical) Effective Date: _____________________
Part IV: Life Insurance Beneficiary Designation
Complete for retiree life insurance coverage and designation, or change of beneficiary. Must be eligible for RCUH Retiree Life Insurance.
The beneficiary of my RCUH Life Insurance plan provided through “The Standard” Insurance Company is: (if a beneficiary of a minor, please see note below)
Primary Beneficiary ________________________________________ Social Security No. _________________________________________ Date of Birth ______________________________________________
(Optional)
Secondary Beneficiary _____________________________________ Social Security No. ______________________________________ Date of Birth _____________________________________________
Applicant Signature: _______________________________________
Relationship Address
Relationship Address
____________________________ ____________________________ ____________________________
____________________________ ____________________________ ____________________________
NOTE: Be advised that life insurance companies will generally not disburse payments directly to minor beneficiaries. Payment will normally be made to the legally recognized guardian of the minor beneficiary, executor of the estate, or The Standard will retain the benefit amount until minor attains majority age.
Date ___________________________________
Part V: Employee/Retiree must sign this part
Information in this application is given to obtain insurance and is true and complete to the best of my knowledge and belief. I authorize my employer to set my effective dates of coverage. I agree to abide by the provisions of the service agreement and health plan regulations. If I am accepted as an HMSA member, I agree to: (a) abide by HMSA’s Constitution and By-laws and the terms and conditions of HMSA’s Health Plan; (b) authorize HMSA to examine and copy any medical records of myself and my dependent for purposes of paying benefits, coordinating benefits with other plans, and conducting quality assurance and health education activities. I further understand that the Kaiser Service Agreement provides that any monetary claim asserted by a Member’s heirs or personal representatives on account of bodily injury, mental disturbance or death must be submitted to binding arbitration instead of a court trial.
Retiree Signature ___________________________________ Date_________________ Daytime Tel. _____________
RCUH Form B-27
Created 06/2008, (Revised 11/2010, 02/2012, 07/18/2014, 3/30/2016)