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(DO NOT STAPLE)
CALIFORNIA
Small Business UnitedHealthcare Insurance Company

Employee Enrollment Form UnitedHealthcare of California

UnitedHealthcare Benefits Plan 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
4
Date of Change Dependent Add/Delete Annual Open Hourly Salary Other
/ / Enrollment COBRA Cal-COBRA
Change Name/Address Late Enrollee Start Date __/__/__ End Date __/__/__
Date of Hire / / Termination Date:___/___/___ Indicate Qualifying Event _______________
Waiving Coverage (Complete Sections A and E)
Life Event/Date ____________________ ___________________________________
Position/Title xxxxx Status Change ____________________ Original Qualifying Event Date
Other ___________________________ 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 Have you or your dependents ever been a
/ / M F Widowed Domestic Partner UnitedHealthcare member? Yes No
Preferred Language: English Spanish Chinese Vietnamese Korean Other ______________________________
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______
Primary Care Physician Name: _____________________________________ Primary Care Dentist Name: ______________________________
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1
John Doe
Address ________________________________________________________ ID#: _________________________________________________
1234 John Doe St.
ID# 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 Date of Birth
Spouse/
M Domestic
Social Security Number l l l l – l l l – l l l l l F Partner _______/_______/_______
Address (if different from Employee) Preferred Language
English Spanish Chinese Vietnamese
Korean Other ____________________________
Primary Care Physician Name: _________________________________________________ Primary Care Dentist Name: __________________________
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1
Address: ___________________________________________________________________ ID#: ______________________________________________
ID# Existing Patient Medical Yes No Existing Patient Dental Yes No
Name (Last, First, M) Sex Relationship 3 Date of Birth

M Dependent
Social Security Number l l l l – l l l – l l l l l F _______/_______/_______
Address (if different from Employee) Please check box when selecting HMO health plan coverage:
Permanently disabled and age 26 or older Yes No
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Preferred Language
English Spanish Chinese Vietnamese
Korean Other ____________________________
Primary Care Physician Name: _________________________________________________ Primary Care Dentist Name: __________________________
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1
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.16.CA 4/15 400-3688 8/19