Member Application & Change Form - Group …

Member Application & Change Form Instructions: This Application allows you to enroll in a UPMC Health Plan product, or to make certain changes if you are already a Member . Employee name Read the instructions and carefully fill out the form. Please write clearly. (First, MI, Last): Select a Plan Covered Family members You must choose from the plans List full name , coverage option, that are offered by your employer. Social Security number, sex, date For employer use only: You may select only one type of of birth, and email address for Group #: Effective date: medical plan. yourself and each dependent you wish to cover under your UPMC Sub- Group #: Reason for Application Health Plan benefits.

Employee Name (First, MI, Last): 2 Reason for Application 3 Change of Status/Coverage 1 of 2 On this application, references to “Dental” and “Vision” refer to

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  Applications, Name, Change, Members, Member application

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