Fillable Benefits Enroll Form (Eastern Michigan University)

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Benefits Enroll Form (Eastern Michigan University)

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U.S.A. forms for Eastern Michigan University

BROWSE EASTERN MICHIGAN UNIVERSITY FORMS

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9/2016
Benefits Enrollment/Change Form
Please print all information clearly.
Faculty/Staff Information
AC AH AP CA CP CS FA FM LE PE / PT PS VF
Name (Last, First, Middle Initial)
Employee ID
SS#
Work Phone
Male Female
Single Married
Email Address:
@emich.edu
Home Phone
Address New? Yes No
City
State
Date of Birth
Medical and Dental elections for OPEN ENROLLMENT 2017
Please take this opportunity to review your health and dental plan elections. You may change plans, add or delete dependents. Please return
your completed form to the Benefits Office. Changes become effective January 1, 2017.
MEDICAL
PPO Option 5
Simply Blue HSA (High Deductible PPO): submit HSA enrollment form
HMO
Waive Medical Coverage: submit waiver of coverage form
DENTAL
Delta Dental
*Medicaid or Medicare – Are any of your dependents listed below eligible for Medicaid or Medicare? Yes No If Yes, attach a copy of
the Medicaid or Medicare card.
*Insurance Information other than Medicare – Are you or anyone named on this application covered by health insurance from another source?
Yes No If Yes, complete below:
Name of Policy Holder
Name of Employer
Group Number
Dependent Information - You must complete the following section for all additions and/or deletions. Enter the information for each dependent,
and then write A in the medical/dental benefit columns to Add to your coverage or D to Delete from your coverage.
Attention AP, AH, CA, AC, LE, FA, FM and CP employees - Spouses with access to subsidized employer coverage must enroll in his/her employer
coverage prior to enrolling in EMU’s plan (secondary coverage only). If covering your spouse, submit the Health Plan Affidavit for Spouses.
Name
(Last, First, Middle Initial)
Social Security Number
Relationship
Code
1
Gender
(M/F)
Date of Birth
MM/DD/YY
Medical
Dental
*Other
Insurance
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1
Relationship Code - SP = Spouse; D = Dependent; DD = Disabled Dependent; AEA = Additional Eligible Adult; SD = Sponsored Dependent Rider
Marriage Certificate and Federal Tax Return is required to cover your spouse. Birth Certificates are required to cover dependents.
Coverage for dependents is only allowed when certain criteria are met. Other proof of eligibility may be required.
Certification and Signature – I have read and agree to the terms and conditions contained on this form. The information provided above is correct
to the best of my knowledge.
___________________________________________________________________________ __________________________________
Signature of Faculty or Staff Member Date Signed
Benefits Dept. Use Only:
Medical: PPO 007003673- HMO 00116292-
Eff. Date: Transfer to
Service Code:
Dental Group: 1873- Transfer to
Eff. Date:
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Benefits Enroll Form (Eastern Michigan University)

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Completed 23 July 2020

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