Get Aetna Gr-67853-34 2018-2026

Filling out the Aetna GR-67853-34 form is essential for obtaining life and disability coverage. This guide provides a step-by-step approach to ensure that you complete the form accurately and effectively.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to acquire the Aetna GR-67853-34 document and have it ready for completion.
2. In Section A, ensure you provide all required details. Start by filling in the Control Number, Suffix, and Account numbers in field A1. Additionally, include the Employee/Member's Social Security Number in field A2.
3. Next, list both the Employee/Member’s name and address in fields A3 and A4. Make sure to include your authorized representative's telephone number in A5, as well as the Employee/Member’s date of hire in A6.
4. Proceed to fill in the Employee/Member's home and work telephone numbers in A7. Don’t forget to include email addresses for both the Plan Sponsor and Employee/Member in A8 and A9 respectively.
5. In field A10, state the Employee/Member’s annual earnings clearly. Then, check the relevant boxes in A11 for requesting Life and Disability coverages. Provide details such as existing and new amounts of coverage.
6. Indicate the reason for requesting Life coverage in the designated area of A11. For Disability coverages, check the appropriate boxes and enter the current and requested amounts or percentages.
7. Ensure that Section A is signed by your authorized representative in A12 before handing over the form to the Employee/Member for submission.
8. In Section B, the Employee/Member must confirm their name, address, and Social Security Number for accuracy. Complete all fields, particularly listing only the names of individuals requesting coverage.
9. Answer the height and weight requirements in B1. Check applicable boxes regarding dependent child coverage, if necessary, in fields B2a, B2b, and B2c.
10. Complete B3g through B4 for any medical conditions, ensuring comprehensive detail is provided for any checked questions. The form must be signed by the Employee/Member, and if applicable, by the spouse as well.
11. After completing all sections, make a copy for your records before submitting the original to the address specified for Aetna Small Group Underwriting.
12. At the end, monitor for any correspondence from Aetna regarding the coverage decision.

Begin filling out your Aetna GR-67853-34 online today for your life and disability coverage needs.