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2009 OPEN ENROLLMENT REQUEST FORM
2009 OPEN ENROLLMENT REQUEST FORM
University Retiree

YOU ARE CURRENTLY ENROLLED IN THE FOLLOWING BENEFIT PLANS:

Medical Coverage:

Dental Coverage:




Medical Insurance

Please check one box below to indicate your intentions for medical insurance effective January 1, 2009.


RETIREE AND/OR SPOUSE/SAME-SEX PARTNER UNDER AGE 65


United Healthcare Core Point of Service Plan


Continue current Core POS
benefit election as noted above for
calendar year 2009




Enroll *
___ Retiree Only
___ Spouse Only
___ Retiree + 1
___ Retiree + 2 or more



Drop * current Core POS benefit
election as follows:
___ Retiree Only
___ Spouse Only
___ Retiree + 1
___ Retiree + 2 or more




United Healthcare Enhanced Point of Service Plan


Continue current Enhanced POS
benefit election as noted above for
calendar year 2009



Enroll *
___ Retiree Only
___ Spouse Only
___ Retiree + 1
___ Retiree + 2 or more



Drop * current Enhanced POS
benefit election as follows:
___ Retiree Only
___ Spouse Only
___ Retiree + 1
___ Retiree + 2 or more




RETIREE AND/OR SPOUSE/SAME-SEX PARTNER OVER AGE 65


AARP Health Care Options Medicare Supplemental Plan
And Prescription Drug Coverage through UnitedHealth Rx for Groups


Continue current Medicare Supplemental benefit
election as noted above for calendar year 2009



Drop* current Medicare Supplemental benefit election
as follows:

____ Retiree Only
____ Spouse Only



____ Retiree + 1


Note: Please be advised that if you elect to terminate your University of Hartford group medical
insurance coverage, you will not be eligible to re-enroll in a University-offered group plan at a later date.



-OVER-

PLEASE COMPLETE AND SIGN THE BOTTOM OF THIS FORM
YOUR SIGNATURE IS REQUIRED TO PROCESS ALL BENEFIT ELECTIONS.



Dental Insurance
If currently enrolled, please check one box below to indicate your intentions for
dental insurance effective January 1, 2009.

Aetna, Inc. Freedom of Choice


Continue current Aetna Freedom of
Choice benefit election as noted
above for calendar year 2009



Make changes *

___ Drop Dependent(s)


Drop * current Aetna Freedom of
Choice benefit election


Note: Please be advised that if you elect to terminate your University of Hartford group dental insurance
coverage, you will not be eligible to re-enroll in a University-offered group plan at a later date.





* An additional form is required to process this change.

You can download forms on the HRD website at
www.hartford.edu/hrd
Please note that you must
complete all appropriate forms to implement your elected change(s). All forms must be returned to
HRD
no later than Friday, November 7, 2008.


All elections become effective January 1, 2009.


AUTHORIZATION AND RELEASE

I authorize the University of Hartford to enroll me in the plans I have elected. I agree to make the
necessary premium payments for all elected coverage. I will submit all payments directly to the Bursars
Office on a monthly basis for as long as I am enrolled in the plan(s).
My signature below indicates that I have read and understand this election form and descriptive
material provided. The election(s) I select are binding for one year and cannot be revoked or modified
except under limited circumstances (qualifying events) as defined by IRS regulations.
I declare that the dependents enrolled are my eligible dependents. I declare that the information
furnished on this form is true, correct and complete to the best of my knowledge.


__________________________________________________________ ______________

Signature Telephone Number Date





To be completed by HRD:
____ Enrollment form(s) processed ____ Initials
____ Insurance Billing Transmittal completed ____ Date