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Below, you will find a preview of the new Aetna Enrollment Form, as well as instructions how to complete it via DocuSign.
Please follow the instructions below to learn more about what information is needed for each sections.
If you have any questions filling out the Aetna Enrollment Form, please email benefits@reliant.org
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If you are enrolling in Aetna Converge through Reliant's annual Open Enrollment period - please see 2021 Open Enrollment Form Instructions (International) |
Since some of the headings of the Aetna enrollment form are blocked from view with the Docusign boxes, below is an example of a filled-out form with instructions.
Please manually type in information. Pre-filling or auto-filling may cause the form to fill wrong boxes with the same information. Example: pre-filling "United States" in the field for country, may cause "United States" to fill other fields. If this happens, delete the auto-filled fields and type in the correct information.
Section C:
Box 1. Employee SSN
Box 2a. Three boxes: (Legal name)
- Employee Last name,
- Employee First Name,
- Middle Initial (optional)
Box 3. Select Mr., Mrs., Miss, Ms.
Box 4. pre-filed "active"
Box 5. Country of Citizenship
Box 2b. Three boxes: List name as you want it to appear on the medical ID card and Explanation of Benefits
- Employee Last name,
- Employee First Name,
- Middle Initial (optional)
Box 6. Gender - select Male or Female
Box 7. Birthdate (of employee)
Box 8.Five boxes - Mailing address
- Large box - Street address
- City: City
- Small hidden box: State
- ZIP/Postal Code: Zip code
- Country: Country
Box 9. Employee Residence Information - Click the appropriate box
- Same as mailing address
- Resident Address differnt from mailing address
Box 10. Four boxes (optional)
- Email address:
- Telephone Number (box to the right of email):
- Work telephone (box below email):
- Fax Number - put "NA"
Section D: Individuals Covered
- First Box: leave as "A" Add
- Relation Code: Use drop down to select from the following:
- EE - Employee (re-type the employee's info on this row to cover them self on this policy)
- W = Wife
- H = Husband
- D = Daughter
- S = Son
- 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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