Epstein Secrets

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

u intend to join one? o Yes c No Primary Care Physician' Physician First & Last Name Address Existing Patient? o Yes o No Primary Care Dentist' Dentist First & Last Name ID# ID# — Existing Patient? r Yes III No B. Waiver of Coverage Declining Spouse's Covered COBRA Tri-Care .__ I (vie) o Other coverage d

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

gin currently participating one? Yes No Primary Care Physician' Existing Patient? Yes Physician Firs & Last Name No Primary Care Dentist' Dentist First & Last Name Existing Patient? Yes No Address IDS IDS Relationshipi Last Name First Name MI Sex o M 0 F Date of Birth / / Dependent Social Securi

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

do you intend to pin one? : ) Yes o No Primary Care Physician' Existing Patient? E Yes Physician First .6 Last Name 2 No Primary Care Dentist' Dentist First & Last Name Existing Patient? o Yes L: No IDS Address IDS — Relationship' Last Name First Name MI Sex - : M F Date of Birth / / Dependent Social