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If you are enrolling in Aetna Converge through Reliant's annual Open Enrollment period - please see (insert page) |
Since some of the headings of the Aetna form are blocked from view with the Docusign boxes, below is an example of a filled-out form with instructions.
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- Name - Last, First, Middle Initial
- US Social Security Number XXX-XX-XXXX
- Birth date MM/DD/YYYY
- Skip 5 check boxes - not required
- Primary Country of Citizenship - USA
- Residence (Indicate if same or Different than the employee (ex. children covered under plan but living in different country for school etc.. )
- If different we may ask for the mailing address separately
- Special Remarks Box:
If you have more than 4 people you're enrolling or adding, please use the Special Remarks box to indicate you need to enroll additional people and finish completing the form. Reliant will amend your Docusign form after you've submitting it to us, and send it back to you with an additional page for you to enter the remaining dependents.
Section E: Acknowledgements - Signatures Required
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