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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.

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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 

UI Steps


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Section 1: Policy / Plan Details

This section is to be done by Reliant office staff. Nothing needs to be completed by you at this time.


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Section 2: Employee Details

Covered Member Details

This is where you will fill out your personal details. The boxes outlined in red are required and will not let you move forward without completing them.

  • Last Name: full legal last name
  • First Name: full legal first name
  • MI: middle initial (optional)
  • Date of Birth: input in Day, Month, Year format (example: 1 January 2023)
  • Male / Female: select whichever applies to you

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Section 3: Contact Details

Employee Mailing Address

Please input the address where you would like to receive mail.

  • Email address: this can be your reliant.org email address or another email address you have access to
  • Telephone Number
  • Country
  • Mailing Address line 1
  • Mailing Address line 2 (optional)
  • Mailing Address line 3 (optional)
  • City
  • State / Province (if outside of the US)
  • Zip Code

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Resident Location

This is the country or location where you are physically present for at least half of a one-year period.

Note

If your Resident Location is the same as your mailing address, you can check the box that says "Check If same as the mailing address."

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This will eliminate the boxes, and we will use your mailing address information for your resident location.

If it's not the same as your mailing address, fill out the sections below:

  • Country
  • Mailing Address line 1
  • Mailing Address line 2 (optional)
  • Mailing Address line 3 (optional)
  • City
  • State / Province (if outside of the US)
  • Zip Code

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Section 4: Additional Information

Citizenship

Please input your primary country of citizenship.

You can add two additional citizenships if desired. If you have more than 2 additional citizenships, please email benefits@reliant.org

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Home/origin location

This is the location where the employee resided prior to their assignment and maintains a residence to return to during or following their assignment.

  • Country
  • City
  • State / Province
Note

If your Home/origin Location is the same as your mailing address, you can check the box that says "Check If same as the mailing address."

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This will eliminate the boxes, and we will use your mailing address country, city and state for your home/origin location.



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Dependents

Here is where you can add dependents if desired.

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titleIf you are adding dependents, please select "yes"

Boxes will appear, and you can add your dependents. You can add up to seven dependents. If you need more than seven, please email benefits@reliant.org to get them added to your insurance plan.

  • Dependent's Full Legal Name
  • Dependent's Relationship to you (husband, spouse, daughter, son)
  • Dependent's Birth date
  • Dependent's Primary Country of Citizenship

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titleIf you are NOT adding dependents, please select "no"

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Nothing more needs to be done. You can move on to the next section.



UI Step

Signatures

Sign the document, and adopt the signature if needed.

Then click "Finish" to submit your form.

Warning

If you miss anything, the form will require you to complete the red boxes before you can select "finish."

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Tip

If you see the option to download and print your form, then your form is submitted!

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Info
titleOpen Enrollment Instructions - See Special Link

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 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. 

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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

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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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