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o enroll)" c Enrolled in Part B: Effective Date c Enrolled in Part D: Effective Date Reason for Medicare eligibility: O Over 65 Are you receiving Social Security Disability Insurance (SSDI)? ci YES O NO Start Date O Ineligible for Part B* O Not Enrolled in Part B (chose not to enroll)** c Ineligible for Part D* c Not Enrolled

Virgin Islands To speed the enrollment process, please be thorough and fill out all sections that apply. To Be Completed by Employer Group Name ( UnitedHealthcare Requested Effective Date of Coverage/Date of Change / / Policy Number Date of Hire Position/Title Hours Worked per week Salary $ Required on

chose not to enroll)' • Reason for Medicare eligibility: o Over 65 o Kidney Disease o Disabled o Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? o YES o NO Start Date Medicare — Spouse/Dependent Name: o Enrolled in Part A: Effective Date c Ineligible for Pail A' o Not Enrolled in

all dependents Employee Enrollment Form Virgin Islands To speed the enrollment process, please be thorough and till out all sections that apply. UnitedHealthcare To Be Completed by Employer Requested Effective Date of Coverage/Date of Chang Group Name Policy Number Date of Hire oto / 0/Awf Reason for Ap

in Part D: Effective Date Reason for Medicare eligibility: Over 65 • Kidney Disease Disabled (2 Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? , . YES c: NO Start Date ___ If enrolled in Medicare, please attach a copy of your Medicare ID card. Ineligible for Part A' Not Enrolled

Unitedlieethcare Compass, Navigate, Select Select Plus. and other products requiring you to choose a primary Care Physician (PCP), you must use the UnitedHealthcare directory al providers to choose a PCP for yourself and each of your covered dependents. (3) Please see employer representative as some dental plans