Lovelace Enrollment Form

• For existing employer groups to enroll new hires
• For current members to notify Lovelace of changes (change of address, addition of dependent, etc.)
• This form can be used for new accounts only after Lovelace has been notified that the employer group has elected our plan, and an account number has been assigned

Instructions for completing:

Please note that this is a two-sided form. Both new hires and current members should be aware of the provisions on the back of the form before they complete and sign the form. The member and the employer group should each retain a copy of the enrollment form for their records.