Group Enrollment Form
PART 1:  Yacht / Employer Name:
This enrollment is for: Employee Only
Employee Name: (last) (first) (middle initial)
Position: Sex: MaleFemale Height: Weight:
Resident Address:
Address Line 1:
Address Line 2:
Address Line 3:
US Address Only    City: State: Zip:

- or -

Non-US Address    City, Country, Postal Code:
  ID# or SSN:   Telephone:   E-Mail:   Citizenship:
  Date of Birth:   Hire Date:  
  Date of Departure from US:  Please check if already departed:   
  Destination Countries:
  For multiple selections:
  On PC - hold down <Ctrl> key
  On Mac - hold down <Command> key
  Or Press
   		Destination(s) Selected:

I Refuse Coverage for: Myself                              Reason:

I have been given the opportunity to participate in the group insurance plan offered through my employer and I have refused to participate in the coverage. I understand that if coverage is desired at a later date, I may be required to furnish, at my own expense, satisfactory evidence of insurability before coverage becomes effective.

Date: Name:
1. Are you currently pregnant, hospitalized or disabled?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE MEDICAL CONDITION INCLUDING DIAGNOSIS, DATES OF TREATMENT, TYPE OF TREATMENT, PROGNOSIS, PRESENT COURSE OF TREATMENT, PHYSICIAN NAME/ADDRESS/PHONE:



2. Have you ever been diagnosed, treated or tested positive for acquired immune deficiency syndrome (AIDS), AIDS related complex (ARC), lymphadenopathy syndrome or any immune system disorder?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE MEDICAL CONDITION INCLUDING DIAGNOSIS, DATES OF TREATMENT, TYPE OF TREATMENT, PROGNOSIS, PRESENT COURSE OF TREATMENT, PHYSICIAN NAME/ADDRESS/PHONE:

3. Have you ever been diagnosed, treated (including medications) or tested for: cancer, diabetes, high blood pressure, neurological, or any cardiac, cardiovascular, heart or circulatory condition?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE MEDICAL CONDITION INCLUDING DIAGNOSIS, DATES OF TREATMENT, TYPE OF TREATMENT, PROGNOSIS, PRESENT COURSE OF TREATMENT, PHYSICIAN NAME/ADDRESS/PHONE:

4. During the last 24 months have you been diagnosed, treated (including medications) or tested for any medical condition or mental health condition?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE MEDICAL CONDITION INCLUDING DIAGNOSIS, DATES OF TREATMENT, TYPE OF TREATMENT, PROGNOSIS, PRESENT COURSE OF TREATMENT, PHYSICIAN NAME/ADDRESS/PHONE:

5. During the last 24 months have you been advised or recommended to have testing , treatment or surgery or do you anticipate testing, treatment or surgery for any medical or mental health condition or problem?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE MEDICAL CONDITION INCLUDING DIAGNOSIS, DATES OF TREATMENT, TYPE OF TREATMENT, PROGNOSIS, PRESENT COURSE OF TREATMENT, PHYSICIAN NAME/ADDRESS/PHONE:


PART 2: Beneficiary information is necessary only if your group offers a Term Life benefit.
Beneficiary Name: Type: Relationship: % of Death Benefit:
Beneficiary Name: Type: Relationship: % of Death Benefit:
Beneficiary Name: Type: Relationship: % of Death Benefit:
Beneficiary Name: Type: Relationship: % of Death Benefit:

PART 3:
Have you been insured or covered for medical expenses under any individual or group policy or plan during the last 12 months?
YES NO
If you answered yes, please provide the name(s) of the Insurance Carrier(s) and the corresponding Policy ID number(s)
I have read the above statements and all attachments or they have been read to me. The statements are true and complete to the best of my knowledge and belief. I understand that any misrepresentation contained herein will void the insurance and all claims will be forfeited. I understand no coverage is effective until I am notified in writing. I authorize any licensed agency, insurance agency, insurance company, group policy holder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial and employment status of the individual, to provide this information to HCC Medical Services Insurance.

Check here to acknowledge agreement to the above statement.     Employee name:     Date: 02/07/2012