Group Enrollment Form PDF

Employee No.
MEMBER ENROLLMENT FORM

PLEASE USE BLOCK LETTERS WHEN COMPLETING THIS FORM
EMPLOYER/COMPANY NAME:
FOR EMPLOYER USE:

POLICY No.
ACCOUNT No.
Mth
DATE HIRED:
Day
Year
LOCATION:
Mth
EFFECTIVE DATE:
Day
Year
SALARY:
PER: WK
MTH
ANN
$
REMARKS:
EMPLOYEE INFO:
EMP. TRN
**All fields in the Employee Info Section must be completed before processing can take place**
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
Mth
Day
Year
MIDDLE INITIAL:
SEX (M/F)
OCCUPATION:
MARITAL STATUS
(S/M/W/D):
BANK INFO:
BNS
FCIB
NCB
Branch:
CONTACT INFORMATION:
Address Line 1
CITI
FGB
Address Line 2
RBTT
Telephone
Cell Phone
Other
E-Mail Address
Account #:
BENEFITS ELECTED:
LIFE
Account Type:
Chequing
Savings
AD&D
N
DISABILITY INC.
Y
MED
DEPENDENT LIFE
HMO
DENTAL
EE Only
EE Only
EE Only
DEP (S)
DEP (S)
DEP (S)
SUPPLEMENTAL LIFE
PARENTAL LIFE
OPTICAL
EE Only
DEP (S)
CRITICAL ILLNESS
SELECTED HMO CENTRE (Where applicable):
I understand that all covered services with respect to the HMO Plan must be obtained through my selected HMO Centre.
DEPENDENTS:
LAST NAME:
FIRST NAME:
TRN:
Day
MIDDLE INITIAL:
Mth
Year
DATE OF BIRTH:
SEX (M/F)
RELATION (S/C)
LAST NAME:
FIRST NAME:
TRN:
Day
MIDDLE INITIAL:
Mth
Year
DATE OF BIRTH:
SEX (M/F):
RELATION (S/C):
LAST NAME:
FIRST NAME:
TRN:
Day
MIDDLE INITIAL:
BENEFICIARIES:
Mth
Year
DATE OF BIRTH:
SEX (M/F):
RELATION (S/C):
PLEASE NOTE: All Beneficiaries listed below are deemed to be revocable beneficiaries unless otherwise stated.
If the beneficiary elected is less than 16 years of age, an adult must also be appointed as Trustee
LAST NAME:
MIDDLE INITIAL:
FIRST NAME:
RELATIONSHIP:
% ALLOCATION:
TRUSTEE NAME:
LAST NAME:
MIDDLE INITIAL:
FIRST NAME:
RELATIONSHIP:
% ALLOCATION:
TRUSTEE NAME:
LAST NAME:
MIDDLE INITIAL:
FIRST NAME:
RELATIONSHIP:
% ALLOCATION:
TRUSTEE NAME:
As provided under my Employers Group Contract with Sagicor Life Jamaica Limited, I elect coverage as indicated above on behalf of myself and my eligible dependent(s) as listed above (where applicable) and authorize my
employer to deduct from my earnings the contributions required (if any) for the benefits elected.
Having elected a Medical (including HMO), Dental and/or Optical Plan, I authorize Sagicor Life Jamaica Limited to have access to, and copies of, all medical, Hospital or other institution/agency records relating to the diagnosis,
treatment or services provided to me or a covered dependent.
I hereby instruct my employer that, in the event of my death, all proceeds, payments or benefits which become due be paid to the person(s) named above under, BENEFICIARY, and reserve for myself the sole right to change my
instructions by informing my employer in writing.
I certify that the above information is correct to the best of my knowledge and confirm that I understand the conditions as stated above.
* I understand that the Effective Date of this insurance is subject to (a) my being actively at work on the day in question; (b) the rules and conditions of the companys underwriters as laid out in the Group Insurance Contract.
SIGNATURE OF EMPLOYEE: __________________________________________

DATE: _________________________
[If employee is applying for coverage outside of eligibility period, please complete Health Statement on reverse]
EBD-STT09-08-J01/0608
GROUP INSURANCE STATEMENT OF HEALTH

PART A TO BE COMPLETED BY THE EMPLOYEE USING BLOCK LETTERS OR PRINT
IMPORTANT:
ALL QUESTIONS MUST BE ANSWERED USING YES, NO OR N/A
EMPLOYER:
EMPLOYEE:
Group Policy Number:
Employees Date of Birth:
Occupation:
Date Employed:
Height:
Relationship to Employee
Eligible Dependents (Spouse/Children)
Weight:
Weight
Height
Place Tick [ ] in Box ..

Have you or any of your dependents ever been diagnosed or treated for:
Employee
Yes No
Date of Birth
Spouse
Yes No
Children
Yes No
1. Any physical impairment?

2. Epilepsy, nervous breakdown, or any disorder of the brain or nervous system?
3. Tuberculosis or any disorder of the lungs, bronchial tubes, throat or respiratory system?
4. Allergies, hay fever or asthma?
5. Ulcer, colitis, or any disorder of the stomach, intestines, rectum, gall bladder or liver?
6. Hemorrhoids or rectal polyps or any disorder of the prostate?
7. Sugar or Albumin or blood in urine, or any disorder of the kidneys, urinary system, female or male
organs, or breasts?
8. Diabetes, gout or any disorder of the thyroid or other glands?
9. Any disorder of the eyes, ears, skin, muscle, bones or joints?
10. Cancer, tumour, cyst or lump?
11. Any disorder of the blood, heart or circulatory system?
12. HIV, Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC)?
13. Infertility, miscarriage or abortion?
14. Any disorder or injury involving the spine or skeletal system?
15. Arthritis, neuritis or rheumatism or any other connective tissue disorder?
During the past five (5) years, have you or any of your dependents:
16. Consulted, been examined or treated by any physician or practitioner?
17. Had an X-ray, electrocardiogram or any laboratory test or study?
18. Had observation or treatment at a clinic, hospital or sanitarium?
19. Had or been advised to have a surgical operation?
20. Consulted a psychiatrist or psychologist?
21. Received medical treatment for any disease, condition or disorder not indicated above?
22. Are you or any of your dependents now pregnant? If Yes, state expected date of delivery.
If any of questions 1 21 are answered, Yes, give complete details below: [continue on additional sheet, if necessary]
Quest.
No.
Full Name of Person Treated
Date(s) of
Visit(s)
Nature of Ailment
Degree of Recovery
(F = Full; P = Partial;
C = Continuing)
Complete Name & Address of

Attending Physician/Dentist
Authorization to Obtain and Release Information:

I declare that all statements are full, true and complete; I understand that they form the basis upon which any insurance will be made effective. I authorize
my Physician, Hospital or any other medically related facility to disclose to Sagicor Life Jamaica Limited information about my health, habits or medical
history as well as that of any dependents listed. It is further understood that Sagicor Life Jamaica Limited reserves the right to request an examination by
a Physician of their choice.
Date: _______________________________
Signature of Employee: _________________________________________________________
PART B TO BE COMPLETED BY EMPLOYER [Continue on additional sheet if necessary]

1. Is the employee now at work and able to perform full duties?
2. Is the employee employed full-time, working more than 30
hours every week?
3. Has the employee been absent from work due to sickness or
injury during the past 6 months?
4. Do you know of any prior or existing serious physical
impairment, history of drug abuse or alcoholism?
Date: ______________________
EBD-STT09-08-J01/0608
Yes
No
If No, give details ___________________________________
Yes
No
If No, give details ___________________________________
Yes
No
If Yes, give details __________________________________
Yes
No
If Yes, give details __________________________________
Signature for Employer: _________________________________
Title: ________________________________

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Employee No.

MEMBER ENROLLMENT FORM

FOR EMPLOYER USE:

SELECTED HMO CENTRE (Where applicable):

SIGNATURE OF EMPLOYEE: __________________________________________

GROUP INSURANCE STATEMENT OF HEALTH

ALL QUESTIONS MUST BE ANSWERED USING YES, NO OR N/A

Group Policy Number:

Employees Date of Birth:

Eligible Dependents (Spouse/Children)

Place Tick [ ] in Box ..

1. Any physical impairment?

Full Name of Person Treated

Complete Name & Address of

Authorization to Obtain and Release Information:

Signature of Employee: _________________________________________________________

PART B TO BE COMPLETED BY EMPLOYER [Continue on additional sheet if necessary]

If No, give details ___________________________________

If No, give details ___________________________________

If Yes, give details __________________________________

If Yes, give details __________________________________

Signature for Employer: _________________________________

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