Forms

For most benefits activities a form must be completed. Below are the forms required for most Health and Life Insurance actions. Make sure you are using the correct form and are following the instructions provided.

Health Insurance: Enrollment

The insurance plan you're eligible for depends on your location and term of appointment. If you or a dependant are located in the US, you must select a US-based insurance plan (Aetna or Empire). Vanbreda is only for staff member and their dependants located overseas who will not require health care in the US. MIP is only for locally-recruited staff members in duty stations away from Headquarters. For most situations (new hire, change in duty station, new addition to the family, etc.) you have 31 days from the event date (e.g., date of birth, date of marriage, etc.) to enroll in the plan.

Step 1: Review your details in Umoja via Employee Self Service (ESS) or for those not using Umoja, confirm with your OHRM that all eligible dependants are listed in appropriate Human Resources Systems as the Insurance Section can not add dependants or make changes to indicative data such as name, date of birth, etc.

Step 2: If you are a new hire your Personnel Action form (PA) should be completed and processed before enrollment. However, if your PA is processed after 31 days please contact the Insurance Section for additional assistance, so that the enrolment window may be extended in ESS.

Step 3: Complete the enrollment process in Umoja via Employee Self Service (ESS) or for those not using Umoja, complete the applicable insurance enrollment form (Print Clearly Use Black Ink)

Step 4: For those not using Umoja, forward the completed form and supporting documents, such as your PA, to the Insurance Section

Step 5: Keep a copy of the enrollment form for your records

Health Insurance: Claims

Please follow the guidelines below in order to submit a claim: 

  • Contact your insurance carrier in order to obtain information about how to file a claim as well as the relevant claim forms. You may do so by visiting their website or by calling the member services number on your insurance card;
  • Complete the claim form per the instructions on the form (Print Clearly; Use Black Ink);
  • Forward the original signed form(s) to the appropriate insurance carrier;
  • Keep a copy of the claim form(s) and all supporting documentation for your records.

Health & Life Insurance: Conversion

If you are interested in the possibility to continue health insurance coverage or continue life insurance coverage once you leave the UN insurance programme, you must review the current applicable Information Circular regarding conversion possibilities and contact the applicable insurance carrier to find out their process of conversion benefits, if applicable. 

  • Following the passage of the Affordable Care Act in the United States and the offering of health insurance plans in the state or federal marketplace exchanges, the United Nations United States-based plans (Empire, Aetna, HIP) no longer offer private plans under what was previously referred to as the “conversion opportunity”. Staff members (subscribers) who cease employment with the United Nations and do not qualify for after-service health insurance benefits, or formerly covered spouses or children, are directed to the insurance exchanges operated by their states of residence or the federal Government to arrange for medical coverage under an individual contract.  
  • CIGNA Dental does not have conversion benefits.
  • Cigna International, UN WWP, allows for continuation of coverage under an individual plan. The conversion policy does not stipulate the coverage level or cost the insurance carrier will apply to your individual plan. You must contact Cigna International regarding conversion benefits within 31 days of your UNHQ coverage ending.
  • Aetna Life Insurance allows for continuation of coverage under an individual plan. The conversion policy does not stipulate the coverage level or cost the insurance carrier will apply to the individual plan. Therefore, you must contact Aetna Life Insurance (1-800-882-8395) regarding conversion benefits within 31 days of your UNHQ coverage ending per the Aetna Conversion Overview.  

Life Insurance: Enrollment

In order to guarantee life insurance coverage, you must complete and turn-in your enrollment form within the first 60 days of employment.  If your form is not completed and returned within that time period you will have to complete an "Evidence of Insurability" form and coverage will not be guaranteed.

Step 1: Complete the Life Insurance Application form (Print Clearly; Use Black Ink)

Step 2: Turn in the completed form

Life Insurance: Beneficiary

Review the forms listed below to ensure you select the correct form for your particular situation.

Step 1: Review the form to ensure that you have selected the correct form

Step 2: Complete the form (Print Clearly; Use Black Ink)

Step 3: Forward the completed form to the Insurance Section at UNHQ

Life Insurance: Evidence of Insurability

If you did not sign-up for Life Insurance within 60 days of employment with the UN, you must complete the "Evidence of Insurability Statement".  Once 60 days of employment has passed, TheHartford reserves the right to deny coverage.

Step 1: Download the form

Step 2: Complete all fields on the form; the form will be returned unprocessed if all fields are not complete (Print Clearly; Use Black Ink)

Step 3: Ensure that your email address is clearly indicated in Box 9 as TheHartford will communicate directly with you if additional information is needed.

Step 4: Submit the form to the Insurance section at UNHQ

Medicare Part B

As you may be aware, the UNHQ Health & Life Insurance Programme has made Medicare Part B a requirement effective 1 January 2011 for all eligible ASHI participants who have not yet attained age 75 as of 1 January 2011 in an effort to contain medical cost. Please find below various Medicare-related forms:

Checklists

In an effort to assist staff members, retirees, surviving spouses, and Human Resources Officers in providing the necessary documentation for special situations, the Health and Life Insurannce section has created the following checklists.

2020 Annual Campaign Form

The 2020 Annual Insurance Campaign for the UNHQ Health Insurance Programme will be held during June 2020. If you are are moving from Aetna to Empire or the reverse and have out-of-network expenses, please use the 2020 Annual  Campaign Form if you cannot access ESS:

2020 Annual Campaign - Deductible Credit Request

The 2020 Annual Insurance Campaign for the UNHQ Health Insurance Programme will be held during June 2020. If you are are moving from Aetna to Empire or the reverse and have out-of-network expenses, please use the 2020 Deductible Credit Request form if needed: