2019-20 Insurance Enrollment Form (OEBB)
Classified
1. Employee
Information
Social Security Number
L#
Last Name
First Name
Date of Birth
Gender
M F
Address
City
Zip
Preferred Phone
If cell phone, do you wish to receive
text message reminders from OEBB?
Yes No
Preferred Email
Are you eligible for Medicare due to age or disability? Yes No
Are you serving, or did you ever serve, in the military? Yes No
If yes, do you authorize OEBB to send your name and address to Oregon Department of Veterans’ Affairs (ODVA) for
the purpose of receiving benefit information?
Yes No
Ethnicity (select one): Hispanic Non-Hispanic/Non-Latino Refused Unknown
Race (select one or more,
circle one as primary):
Asian Black/African American American Indian/Alaska Native White
Native Hawaiian/Other Pacific Islander Other Refused Unknown
2. Dependent
Information
Attach separate sheet if
necessary.
Relationship Codes (“Rel. Code” below – Please indicate one per dependent.)
SP=Spouse, CH=Employee and/or Spouse’s child, DD=Disabled Dependent, DP=Domestic Partner*,
DP CH=Domestic Partner’s Child*
Ethnicity Codes (Please indicate one per dependent below.)
1=Hispanic, 2=Non-Hispanic/Non-Latino, 3=Refused, 4=Unknown
Race Codes (Please indicate one or more per dependent below. If more than one, please indicate one primary
race in the next column.)
1=Asian, 2=Black/African American, 3=American Indian/Alaskan Native, 4=Native Hawaiian/Other Pacific
Islander, 5=White, 6=Other, 7=Refused, 8=Unknown
Due to Federal Health Care Reform, OEBB is requesting Ethnicity, Race and Primary Race information for all members and dependents. Please
indicate one ethnicity code for each dependent and at least one race code for each dependent. If indicating more than one race code for a
dependent, please also indicate in the next column which one of those race codes is the dependent’s primary race.
Dependent A Add Drop
Medicare Eligible Yes No
* Race/Ethnicity:
Last Name
First Name
MI
Relationship
Social Security No
Birth Date
Gender
M
F
Dependent B Add Drop
Medicare Eligible Yes No
* Race/Ethnicity:
Last Name
First Name
MI
Relationship
Social Security No
Birth Date
Gender
M
F
Dependent C Add Drop
Medicare Eligible Yes No
* Race/Ethnicity:
Last Name
First Name
MI
Relationship
Social Security No
Birth Date
Gender
M
F
Dependent D Add Drop
Medicare Eligible Yes No
* Race/Ethnicity:
Last Name
First Name
MI
Relationship
Social Security No
Birth Date
Gender
M
F
You must report to your employer's benefits administrator within 31 days after a person enrolled as your spouse, domestic partner or
dependent child becomes ineligible for benefits. If you make this report on time, the change will be effective the first of the month after
your report. If you do not report this change on time, OEBB may consider your omission as an intentional misrepresentation of a
material fact, for which OEBB may terminate the dependent’s coverage effective the first of the month after eligibility was lost.
3. Tobacco Usage
Please select one of the following:
Please select one of the following:
This information will be used to
determine your premium amount(s)
for Optional Employee and Optional
Spouse/Domestic Partner Life plans
.
I currently use tobacco products.
I have not used tobacco products
in the past 12 months.
I have never used tobacco
products.
I do not currently have a spouse
or domestic partner.
My spouse/domestic partner
currently uses tobacco products.
My spouse/partner has not used
tobacco products in the past 12
months.
My spouse/domestic partner has
never used tobacco products.
4. Medical, Dental and Vision Plan Selection Indicate a selection for each plan type.
Medical Benefit Plan Selection
Moda Plan 1
Moda Plan 2
Moda Plan 6 (w/ optional HSA)
Kaiser Plan 1
Decline Medical
Explanation
(required if declining):
Dental Benefit Plan Selection
Delta Dental Plan 1
Delta Dental Plan 6
Willamette Dental Plan
Decline Dental*
Vision Benefit Plan Selection
Moda Opal
VSP Choice Plus
Decline Vision
*If you waive benefit coverage now, you may be subject to waiting period restrictions at a later date.
5. Voluntary Life
Insurance
All coverage elections above the guarantee issue amount and/or beyond the guarantee issue period
must be medically underwritten. Please mark the box for all coverage(s) you are applying for. By
selecting “no”, an application for coverage at a later date may require further medical information
and/or physical exam, which may be at the member’s own expense.
Voluntary Employee Coverage
Voluntary Spouse/Domestic Partner Coverage
Life Only (in $10,000 increments): $
Life & AD&D (in $10,000 increments): $
$200,000 Guarantee Issue
$500,000 Maximum Coverage
Life Only (in $10,000 increments): $
Life & AD&D (in $10,000 increments): $
$30,000 Guarantee Issue
$500,000 Maximum Coverage
Employees must elect coverage in order to elect
spouse/partner and/or dependent coverage. Total
employee amount must be equal to or greater than
requested amount for spouse/partner coverage.
Voluntary Dependent Child Coverage
Life Only (in $2,000 increments): $
Life & AD&D (in $2,000 increments): $
$10,000 Maximum Coverage
Beneficiary Information
A contingent beneficiary will receive benefits only if the primary beneficiary does not survive you.
Name and Address
Relationship
Primary or Contingent
Percentage
%
%
%
%
%
6. Voluntary
Long Term Care
All employee coverage elections above the guarantee issue amount and/or beyond the guarantee
issue period must be medically underwritten. Additionally, all spouse/partner coverage must be
medically underwritten. Please contact Human Resources to obtain the application for this process.
Employee Coverage:
Monthly Coverage
(in $1000 increments): $
Duration (check one): 3-Years 6-Years Lifetime
Simple Inflation (check one): with without
Total Home Care (check one): with without
Spouse/Partner Coverage:
Monthly Coverage
(in $1000 increments): $
Duration (check one): 3-Years 6-Years Lifetime
Simple Inflation (check one): with without
Total Home Care (check one): with without
7. Employee Signature and Authorization
I declare the dependents listed above and I are eligible for the coverages requested per OEBB Administrative Rule
(OAR)-Division 10. I have read and understand OAR-Division 10 concerning Definitions and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_010.html
I have read and understand OAR-Division 80, Sections 111-080-0040, 111-080-0045 and 111-080-0050 concerning
Eligibility and Policy Term Violations and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_080.html
I understand I have 31 days to notify my employer of a Qualified Status Change (QSC) which affects eligibility. I have
read and understand OAR-Division 40 concerning Enrollment and can find this OAR at
http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_111/111_040.html
I understand the benefit elections I make are in effect for as long as I continue to meet OEBB's eligibility
requirements, or until I elect to change them subject to the provisions of OEBB's plan. I understand I cannot alter my
plan selections during the plan year unless I have a QSC; then I am subject to the restrictions of the OEBB QSC’s. I
have reviewed and understand the Qualified Status Change (QSC) Matrix and can find the matrix at
http://www.oregon.gov/oha/OEBB/Pages/QSC-Matrix.aspx
I have read the benefit materials and I understand the limitations and qualifications of the OEBB benefits program. If
necessary, I authorize premium payments deducted from my pay, unless I self-pay premiums. If I self-pay the
premiums, I agree to submit monthly payments by the date specified, or my coverage will terminate; I will not be able
to reinstate coverage until the next open enrollment period or may lose OEBB eligibility altogether. A person who
knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment
and fines. Additionally, knowingly making a false statement may subject a person to termination of enrollment, denial
of future enrollment, or civil damages.
This election supersedes all elections and submissions I previously made for OEBB coverage. I hereby declare that the
above statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty
for perjury
.
Employee Signature Date
HUMAN RESOURCES USE ONLY
Coverage Effective Date OEBB E #
PDADEDN PDABCOV Infinisource
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome