Enrollment Form
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Online Enrollment
Employer:
New Enrollment:
No
Yes
Effective Date:
/
/
Addition
No
Yes
Reason for Addition:
Newly Married
Open Enrollment
Other
Effective Date:
/
/
Termination:
No
Yes
Effective Date:
/
/
Elected COBRA?
No
Yes
Qualifying Event?
Termination of Employment
Reduction of Hours
Divorce
Legal Separation
Child Losing Dependent Status
Death of Employee
Medicare Eligibility of Employee
EMPLOYEE/RETIREE INFORMATION
Employee Last Name
First
MI
Phone-Work
Home
ID Number
Street
City, State
Zip
Coverage Type
Single
Family
Employee/Spouse
Employee/Child
Employer Name and Location (city and state)
Hire Date
Status
Active
Retired
Marital Status
Single
Married
Divorced
Seperated
PERSONS TO BE ENROLLED/ADDED/TERMINATED
IMPORTANT: IF YOU DO NOT ENROLL OR YOU DO NOT ENROLL ALL OF YOUR ELIGIBLE DEPENDENTS YOU WILL NOT BE ELIGIBLE UNTIL THE NEXT OPEN ENROLLMENT UNLESS YOU QUALIFY FOR SPECIAL ENROLLMENT
Self-Last Name
First Name
MI
Relation
SEX
Birth Date
Social Security
Dependent Last Name
First Name
MI
Relation
SEX
Birth Date
Social Security
Do you have a child who is a fulltime student?
No
Yes
Documentation from School must be provided -
Instructions
Do you have a disabled dependent child?
No
Yes
Documentation from Employer must be provided -
Instructions
>
OTHER HEALTH COVERAGE/INSURANCE/MEDICARE
IF YOU OR ANY FAMILY MEMBERS ARE COVERED BY ANOTHER HEALTH PROGRAM AND/OR MEDICARE PLEASE COMPLETE BELOW
Insurance Company
Policy Holder
Group Number
ID Number
Effective Date
Insurance Company Address
Phone
Coverage Type
Single
Family
Employee/Spouse
Employee/Child
SIGNATURE
Signature of Applicant (if mailing)
Date
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