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7223 West 95th Street Suite 301
Overland Park, Kansas 66212-2291
1-800-382-4121
https://www.ataamerica.com/

Employee Enrollment / Refusal Form

Instructions for completing this form

Misstatements and omissions made by you on this form may cause you to lose coverage under your employer’s plan. This form must be completed by the EMPLOYEE ONLY. To participate and be covered under the plan, an employee must be a citizen of the United States or an alien legally residing and working in the United States.

After signing below, you will be asked a series of questions. You must answer all required questions before the system will let you submit the form. The form will let you change any of your answers before you affix your signature at the end of this document and hit the submit button on the last page. If you wish to make a change after you have submitted your form, you will need to call 1-800-382-4121. At which time you will be asked to confirm your personal information on the phone; therefore, please verify you enter personal information correctly.You can print a copy for your records after you submit the form.

By signing this form below, I hereby certify that I will complete this form truthfully to the best of my ability.

Please enter your legal name (first and last name spearated by a space) using only the alphabet, spaces, commas, periods, hyphens, and/or apostrophes.

Electronic Enrollment Code

Please provide the group's electronic enrollment code.

Check here if you do not know or have the group's electronic enrollment code.

Step 1: Your Information Please tell us about yourself

First Name

Middle Initial

Last Name

Please provide a first name.

Please provide a last name.

Your Personal Email Address: (optional)

Please enter a valid email address.

Home Address:

Please provide a street address.

City:

Please provide a city.

State:

Please provide a state.

Zip:

Please provide a valid zip code.

Mailing Address:

Check here if your mailing address is the same as your home address

Please provide a street address.

City:

Please provide a city.

State:

Please provide a state.

Zip:

Please provide a valid zip code.

Personal Phone:

Please provide a personal phone number.

Birth Date:

Please provide a birth date.

Social Security Number:

Please provide a social security number.

Marital Status:

Please specify your marital status.

Note that this type of spouse is not eligible under the plan.

Please explain:

Please explain'.

Basic Employment Information

Employment Status:

Please specify your employment status.

Please explain:

Please explain 'other'.

Please be advised that retired employees may not be eligible for coverage.

What is the name of the company you work for and through which you are requesting this coverage?

Please specify the name of the company you work for and through which you are requesting this coverage.

How many hours do you normally work per week for the employer listed in the previous question?

When did your full time employment begin?

I know the approximate date

I know the exact date

More than 10 years ago

Required.

Required field.

What is the date of your COBRA continuation coverage (effective start date)?

I am still in my COBRA election period

Please specify the date.

Step 2: Please elect your coverage

Please tell us what coverage you are electing or declining for all family members (even those not listed in step 3).

Employee Coverage Election

Do you want to elect Medical coverage for the employee (yourself)?

Yes

Please answer yes or no.

Reason for Decline:

*Loss of coverage under Medicare cannot be used as the basis to shorten the waiting period for late enrollees

Please explain "other":

Please explain 'other'.

Please tell us the other plan name:

Please document the other Health Coverage's plan name.

You may not enroll your spouse nor any of your children in medical coverage if you do not elect coverage for yourself.

Do you still want to decline medical coverage for yourself and your family members?

Yes, I would like to decline.

No, please reset the form

Please confirm (yes) or reset the form (no).

If offered by your employer, do you want to elect Dental coverage for the employee (yourself)?

Yes

N/A - Not Offered by Employer

Please answer.

You may not enroll your spouse nor any of your children in dental coverage if you do not elect coverage for yourself.

Do you still want to decline dental coverage for yourself and your family members?

Yes, I would like to decline.

No, please reset the form

Please confirm (yes) or reset the form (no).

Please select the type of health plan option where "high" means the best benefits and highest costs while "low" means the least benefits and lowest costs.

What health plan do you want to select? (You may change this at a later date).

High - Most benefits, highest costs

Medium - Average benefits, average costs

Low - Least benefits, lowest cost

Please select a health plan.

Step 3: Please tell us about individuals who are electing coverage

Only your spouse, natural children, adopted children, and step-children are eligible to be enrolled. If the spouse’s last name is different than the employee’s last name then please provide a copy of the marriage certificate with this enrollment form.

Individuals Electing Coverage - Add Individual
Relationship	Name	Edit/Delete
		Edit - Delete

Before continuing, verify that all individuals to be covered under the plan are listed above.

I have listed all individuals to be covered under the plan.

Please confirm you have listed all individuals to be covered under the plan.

Individual #1 electing coverage: Edit

Relationship to Employee:

Edit

Please specify relationship to employee

Birth Date:

Please provide a birth date.

Gender:

Male

Female

Other

Please indicate gender.

Height: feet inches

Please provide height in feet and inches.

Weight: lbs

Please provide weight in pounds (lbs).

Is this person a tobacco user or an e-cigarette user?

Yes

Please answer yes or no

Type Used:

Years used?

Medicare HIC # (if any):

Social Security Number:

Please provide a social security number.

Does this person live with you at the home address above?

Yes

Please answer yes or no

Please list this person's home address.

Home Address:

Please provide a street address.

City:

Please provide a city.

State:

Please provide a state.

Zip:

Please provide a valid zip code.

Notices, Representations & Authorization Please read this section carefully

Special Enrollment Notice

If you decline medical and/or dental coverage for yourself, your spouse, or your dependents at this time for any reason, you may later be eligible to enroll yourself, your spouse and/or your newly acquired dependent(s) in medical and/or dental coverage within 30 days of acquiring the dependent(s) through marriage, birth, adoption, or placement for adoption. If you decline medical and/or dental coverage for yourself or your dependents at this time because of coverage under other health insurance or group health plan coverage, you or your dependents may later be eligible to apply for medical and/or dental coverage without penalty within 30 days after you or your dependents’ other health coverage ends (or after the employer stops contributing toward the other coverage), but only if you state in STEP 2 that other health coverage is the reason for declining coverage. The penalty for failure to state that other health coverage was the reason for declining this coverage will be a 6-month waiting period under this plan after you apply for coverage hereunder or a wait until the next available open enrollment period if any is provided by the plan

I represent: (1) I am an employee of the employer identified in Step 1 and the persons for whom I am requesting coverage are US Citizens or Aliens legally residing in the USA; (2) the statements and answers to the questions on this Enrollment/Refusal Form made by me are true and complete to the best of my knowledge; and (3) I understand that the statements and answers to questions on this Enrollment/Refusal Form made by me and any subsequent information I provide are the basis for my coverage under my employer’s plan and that coverage will not be effective until I am notified of my effective date.

I authorize: (1) any physician, medical practitioner, hospital, clinic, pharmacy benefit managers, Veteran’s Administration, or other medical-related facility, insurance agent, administrator, insurance company, reinsurer, consumer reporting agency, telephone interview company, or my employer to release any information pertaining to my employment or to the health of myself or my dependents, including physical or mental disorders or the use of drugs and alcohol, to American Trust Administrators, Inc.; (2) American Trust Administrators, Inc. to release such information to any insurance agent, insurance company, reinsurer, managed care organization, telephone interview company, other insurance support organization, or my employer; (3) my employer to deduct contributions from my earnings to be applied to the cost of this plan; and (4) that benefits under this plan be paid directly to any participating managed care provider utilized by me or my family.

I agree this authorization will be valid for two years from the date this form is signed and that an electronic copy or photocopy of this authorization is as valid as the original for my dependents and me.

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information may be guilty of a crime.

By signing this form below, I hereby certify that I have completed this form truthfully to the best of my ability:

Please enter your legal name (first and last name spearated by a space) using only the alphabet, spaces, commas, periods, hyphens, and/or apostrophes.
This must match the signature given at the beginning of the form. You must go back and edit it if you have typed it incorrectly.

ATA9110 Revised 08/25/2019

Employee Enrollment / Refusal Form

Your submission has been received.

Instructions for completing this form

Electronic Enrollment Code

Step 1: Your Information Please tell us about yourself

Basic Employment Information

Step 2: Please elect your coverage

Employee Coverage Election

Spouse Coverage Election

Children Coverage Election

Step 3: Please tell us about individuals who are electing coverage

Individual #1 electing coverage: Edit

Step 4: Health Statement

Basic Health Information for the Employee

Notices, Representations & Authorization Please read this section carefully

Special Enrollment Notice