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EMPLOYEE BENEFIT ENROLLMENT FORM

 New enrollment  Mid-year change  Open Enrollment

A. PARTICIPANT INFORMATION (REQUIRED—COMPLETE IN FULL)

Employee name: ________________________________________________________________________________________________

DMBA ID number: _______________________________________________________________________________________________

Employer name: ____________________________________________________ Department: _________________________________

Employee Social Security number: ________________________________________ Birth date (mm/dd/yyyy): _________________________

Home address: _________________________________________________________________________________________________

City: __________________________________________________ State: ____________________ ZIP code: ______________________

Home phone: ____________________________________________ Work phone: ____________________________________________

Sex:  Male  Female Marital status:  Married  Widowed  Single  Divorced

Spouse name and birth date: _______________________________________________________________________________________

B. CHOOSING YOUR BENEFITS

CHOOSE WHO TO ENROLL:

 Myself  Myself and one dependent  Myself and two or more dependents

CHOOSE YOUR MEDICAL PLAN (*plan availability based on location):

 Deseret Premier  Deseret Select*  Deseret Choice Hawaii*  Deseret Value

 Deseret Protect  Kaiser* (If you choose Kaiser, complete the appropriate Kaiser application for where you live.)

 Waiving medical—Life and Disability only Note: If you wish to waive all benets, see section C below.

CHOOSE YOUR DENTAL PLAN:

 Deseret Dental  Deseret Dental PLUS  Waiving dental

CHOOSE YOUR VISION PLAN:

 VSP with an annual eye exam  VSP without an annual eye exam  Waiving vision

C. PARTICIPANT AUTHORIZATION (REQUIRED)

 I wish to enroll or make changes as indicated on this form.

 I wish to waive benets. (Medical, Dental, Group Term Life, Occupational Accidental Death & Dismemberment, and Disability)

My signature acknowledges that I have read and agree to the terms and conditions of the benets applied for herein.

Signature: ________________________________________________________ Date: _______________________________________

D. EMPLOYER USE ONLY

E03STD1EN0620

Basic GTL salary level: _____________________________________

Action (check all that apply):

 New enrollment (hire date): _____________________________

 Change or other: ____________________________________

 Leave of absence (specify type): __________________________

Employer authorization: ___________________________________

Date: ________________________________________________

Comments: ___________________________________________

____________________________________________________

E. DEPENDENT INFORMATION

I wish to:  Add dependent(s)  Remove dependent(s)

Reason for change: ______________________________________________________________________________________________

For dependent coverage, complete the following information. List your spouse and all legal dependents from oldest to youngest. If you omit any

dependents during initial enrollment, they will not be covered.

RELATIONSHIP TO

EMPLOYEE

NAME

(FIRST, MIDDLE INITIAL, LAST)

BIRTH DATE

(MM/DD/YYYY)

SEX

SOCIAL SECURITY NUMBER

(REQUIRED)

S - Legal Spouse

N - Natural or

Adopted Child

SC - Stepchild

MC - Married

Child

GC - Grandchild

O - Other

(Specify in

Comments)

M F

Dependents added above will be enrolled for the coverage currently in effect. This includes the minimum guaranteed amounts only for Group Term Life and

Supplemental Group Term Life. You may apply for additional Supplemental Group Term Life when the child is six months old. Also, new dependents will be

enrolled for your current level of dependent coverage for 24-Hour Accidental Death & Dismemberment.

F. OTHER MEDICAL OR DENTAL COVERAGE

If you or any dependents are covered by any other medical or dental plan(s), please complete the following information or attach a copy of your health

insurance card(s). If you no longer have your insurance cards, please contact your other insurance carrier and request a letter verifying your coverage and

send it to DMBA.

Other insurance carrier name: ___________________________________________ Phone number: ________________________________

Policy holder: ______________________________________________________ ID number: ___________________________________

Fill Online, Printable, Fillable, Blank EMPLOYEE BENEFIT ENROLLMENT FORM Form

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Fillable EMPLOYEE BENEFIT ENROLLMENT FORM

Fill Online, Printable, Fillable, Blank EMPLOYEE BENEFIT ENROLLMENT FORM Form

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