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
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.
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
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
Resident Location
This is the country or location where you are physically present for at least half of a one-year period.
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."
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
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
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
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."
This will eliminate the boxes, and we will use your mailing address country, city and state for your home/origin location.
Dependents
Here is where you can add dependents if desired.
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
Nothing more needs to be done. You can move on to the next section.
Signatures
Sign the document, and adopt the signature if needed.
Then click "Finish" to submit your form.
If you miss anything, the form will require you to complete the red boxes before you can select "finish."
If you see the option to download and print your form, then your form is submitted!
