To make a change to your Nationwide Health Plan, please ...



To make a change to your Nationwide( Policy, please complete the appropriate section that applies to the change(s) you are requesting

Policyholder’s Name (Please Print):________________________________________ Policy No. _____________________

Address Change Residence Address Billing Address Both

Address:__________________________________________________________________________________________

City:______________________________________________ State:_______________ Zip Code:__________________

Phone Number (if applicable): ( ) ______________ - ________________________ *Note: Relocation may affect your premium rate

Name Change From:____________________________ To:______________________________________

(Please provide proof of name change when submitting the request)

Marital Status Single Married Date of marriage or divorce:___________/__________/_____________

(IF DIVORCE, BOTH INSURED & SPOUSE MUST SIGN FORM) MONTH DAY YEAR

Change In Payment Mode (INDICATE MONTH EFFECTIVE WHERE APPLICABLE): Note: Group billed can only have monthly direct mail bill. The $5.00 fee will NOT be added. Not all payment options are available for all Groups.

Payment Mode Payment Frequency Month Effective

Direct Mail Bill ($5.00 monthly fee will be added) Monthly Quarterly Semi-Annual ____________

Annual

ELECTRONIC FUNDS TRANSFER (EFT) Monthly ______________

Repetitive Credit Card Monthly ______________

Complete the following if EFT is available to you and is chosen as your payment mode:

First and Last Name Printed:______________________________________________________________________

Bank Name:____________________________________________ Account Number:_________________________

Routing Number:________________________________________ ( Checking Account ( Savings Account

Note: Please enclose a voided check along with this form

Change of Beneficiary Subject to the terms of the policy. I hereby request that the Beneficiary on my Life Insurance be changed to the following,

in lieu of any prior beneficiary designations applicable thereof, which are hereby revoked. The change will be effective as of the date the form is signed.

Primary Beneficiary: (To receive proceeds if living at my death)_____________________________________________________

Relationship To Me: ____________________________________________________________________________________

Contingent Beneficiary: (To receive proceeds if living at my death if PRIMARY BENEFICIARY is not then living)___________________

_____________________________________________________________________________________________________

Relationship To Me:_____________________________________________________________________________________

IMPORTANT for CHANGE of BENEFICIARY: Requested change(s) will not be processed without policyholder’s signature

Policyholder’s Signature____________________________________________________________ Date_________________

OR PARENT/LEGAL GUARDIAN OF POLICYHOLDER

Spouse’s Signature________________________________________________________________ Date_______________

AND/OR DEPENDENT IF AGE 18 OR OVER

Witness Signature________________________________________________________________ Date_______________

Add Newborn/Adopted Child (WITHIN 31 DAYS OF BIRTH OR ADOPTION)

First and Last Name:_____________________________________________________ Date of Birth:________________

Relationship To Insured:__________________________________________________ MALE FEMALE

Reason for Addition: Birth Adoption Other:________________________

Note: To add (a) dependent(s) to your policy (except for a newborn added within 31 days of birth), a completed application is required and will be underwritten Please contact your agent or call Member Services at 1-877-837-1861 for assistance.

Remove Dependent(s) from Policy (termination date will be the last day of the month)

First and Last Name:_________________________________ Date of Birth:__________________ Relationship:__________

First and Last Name:_________________________________ Date of Birth:__________________ Relationship:__________

Cancel All Coverage Effective Date of Cancellation:______________/____1_________/_____________

Month Day Year

IMPORTANT: Requested change(s) will not be processed without policyholder’s signature

Policyholder’s Signature_______________________________________________________ Date_________________

Group Administrator’s Signature_________________________________________________ Date_________________

Note: The Group Administrator’s Signature is not required for individual billed members.

Fax Form To: (877) 837-1854 or

Mail Form To:

Nationwide(

, PO Box 30149

, Tampa, FL 33630-3149

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