Aetna Enrollment Election Form

This form is available to those retirees and Medicare eligible dependents that wish to enroll in the University of Maine System sponsored Aetna Medicare Advantage plan. Please contact the insurance carrier that you had enrolled with through the Aon Retiree Health Exchange to cancel your coverage and to pursue reimbursement of any premiums you may have paid to the carrier. Please complete this form for each Medicare Eligible Dependent you wish to enroll in the Aetna plan. If you have provided an email address you will receive confirmation of your elections within 48 hours. Confirmation of your elections will come via USPS, subject to the standard postal delays if no email is provided.

First Name*

Last Name*

Middle Initial

Date of Birth*

Gender*

Medicare Number

Number found on your Medicare card

Primary Address*

PO Box

City*

State*

Zip Code*

Phone Number*

Email Address

Medical Election*

I acknowledge that this form is to certify my enrollment into the University of Maine System sponsored group Aetna Medicare Advantage Plan, and by doing so I attest that I have contacted the carrier I chose under the Aon Medicare Exchange to un-enroll into coverage.

Dental Election*

I am electing to continue my Cigna Dental Insurance, and confirm that I am currently enrolled in Cigna Dental. I verify that I have dis-enrolled in any coverage elected through Aon, if applicable.

Yes

Not Applicable - Choose this if you have never had Cigna Retiree Dental Coverage

Send me a copy of my responses

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