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(DO NOT STAPLE)
CALIFORNIA
Small Business UnitedHealthcare Insurance Company

Employee Enrollment Form UnitedHealthcare of California

To speed the enrollment process, please be thorough
and fill out all sections that apply.
To Be Completed by Employer Group Name/Number Angeles Contractor, Inc.
Requested Effective Date of Reason for Application Employee Type (check all that apply)
Insurance / Health Plan Coverage / New Group Plan  New Hire Active Union Non-Union Retired
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Date of Change Dependent Add/Delete Annual Open Hourly Salary Other _____________
xx / xx / xxxx Enrollment COBRA Cal-COBRA
Change Name/Address Late Enrollee Start Date ___/___/_____ End Date___/___/_____
Termination Date: _____/ _____/ _____
Date of Hire xx / xx / xxxx Indicate Qualifying Event __________________
Waiving Coverage (Complete Sections A and E)
Life Event/Date _______________________ ________________________________________
Position/Title xxxxx Status Change _______________________
Other _______________________________ Original Qualifying Event Date
____________________________________ Start Date ___/___/_____ End Date___/___/_____
Hours Worked Per Week 40

A. Employee Information Complete All Sections
If you are waiving coverage, please complete only Sections A and E
Last Name First Name MI Social Security Number Home Phone/Cell xxx-xxx-xxxx
John M xxx-xx-xxx Work Phone 714-443-3655
Address Apt # City State ZIP Code Email Address
1234 John Doe St. Buena Park CA 90623 johndoe@gmail.com
Date of Birth Sex Marital Status Single Married Divorced
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xx xx M F Widowed Domestic Partner
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/ / xxxx
Preferred Language: English Spanish Chinese Vietnamese Korean Other ____________________________________
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Primary Care Physician Name: ___________________________________________ Primary Care Dentist Name: __________________________________
John Doe
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1234 John Doe St.
Address _______________________________________________________________ ID#: ______________________________________________________
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ID# x x x x x x x x x x Existing Patient Medical Yes No Existing Patient Dental Yes No
B. Dependent Information List All Enrolling (attach sheet if necessary)
Name (Last, First, M) Sex Relationship 3 Birth Date
None Spouse/
M Domestic
Social Security Number – – F Partner ___/___/_______
Address (if different from Employee) Preferred Language
English Spanish Chinese Vietnamese
Korean Other ________________________________
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Primary Care Physician Name: _______________________________________________________ Primary Care Dentist Name: ______________________________
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Address: __________________________________________________________________________ ID#: ___________________________________________________
ID# Existing Patient Medical Yes No Existing Patient Dental Yes No
Name (Last, First, M) Sex Relationship 3 Birth Date
M Dependent
Social Security Number – – F ___/___/_______
Address (if different from Employee) Please check box when selecting HMO health plan coverage:
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Permanently disabled and age 26 or older Yes No
Preferred Language
English Spanish Chinese Vietnamese
Korean Other ________________________________
Primary Care Physician Name: _______________________________________________________ Primary Care Dentist Name: ______________________________
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Address: __________________________________________________________________________ ID#: ___________________________________________________
ID# Existing Patient Medical Yes No Existing Patient Dental Yes No
IMPORTANT: (1) Please use the UnitedHealthcare Provider Directory to select a Primary Care Physician for yourself and each of your covered dependents
for products requiring a Primary Care Physician designation. (2) Please use the Dental Directory to select a Primary Care Dentist for yourself and each of your
covered dependents for products requiring a Primary Care Dentist designation. (3) For court-ordered dependent, legal documentation must be attached.
(4) Applicable to HMO health plan coverage selection: If you answered “Yes” for Disabled and the dependent child is 26 years of age or older, unmarried, chiefly
dependent upon subscriber for support and is not able to be self-supporting because of a physically or mentally disabling injury, illness or condition, please attach
a medical certification of disability.
SG.EE.14.CA 6/13 400-3688 2/15