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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