Existing Patient:
c
Hourly
c
Salary
c
Open Enrollment
I am Refusing all Health Coverage at this time. I understand that if I decide to apply later coverage may not be available unti
l the
next open or special enrollment period.
Plan
#
03160 Hi Deductible @ $1
40
0
Employee Only
Please type or write clearly in black or blue ink.
Employee Enrollment Application
Section B: Employee Information
Section C: Health Coverage Level and Plan Information
Effective Date of Coverage: Location #:
Work Status:
Employee #:
Social Security #:
22095 0914R SR
Last Name:
First Name:
M. I.:
Street Address: Apt. #: City: State:
County: Marital Status:
Retirement Date:
Paid:
Job Title:
Sex:
c
M
c
F
Legally
Separated
Ethnicity
optional
Check all that apply:
Employee Health Coverage:
* When available
Date of Hire:
Birth Date:
Zip:
Phone:
Language of Preference: optional - for data collection purposes only
Physician Name / ID #
Signature:
Date:
Plan
#
03161 Hi Deductible @ $2
8
00
*Employee
& Spouse
*Employee
&
Child(ren)
Family
c
Yes
c
No
c
English
c
Spanish
c
Other
c
Prefer not to answer
c
Single
c
Married
c
Divorced
c
Widowed
c
c
Actively at Work
c
Cobra
c
Retired
c
Asian/Pacific Islander
c
Black/African American
c
Caribbean Islander
c
Hispanic
c
Native American
c
White
S
ection A: Current Information
Group Name: Group #: Division #:
Package #:
Sectio
n
D
: D
ependent Information
Attach separate sheet, if additional space is needed, with dependent information, sign & date.
Bay County Board Employees
Ethnicity
optional
Circ
l
e all th
a
t
app
l
y.
S
ocial
S
ecurity
N
umber:
Bi
r
t
h
D
a
te:
Last Name:
(if
different than employee)
First Name, M.I.
You Support
Exi
sting
P
atient
(Y
/
N)
Lives With You
Is
a Student
R
elation to
Y
ou
Spouse (S)
Domestic Partner (DP)
Other (O)*
Dependent
Physician
Name/ID
HMO only
A B
C
H N W
A B
C
H N W
A B
C
H N W
A B
C
H N W
A) Asian/Pacific Islander
B) Black/African American
C) Caribbean Islander
H) Hispanic
N) Native American
W) Whit
e
Sex (M or F)
Check if Disabled
List the name of each dependent listed above that is married or has dependent child(ren) or lives outside of Florida.
Plan
Type
Health
Vision
Domestic Part. Child (DPC)
Child (C)
I
n addition to this policy, do you or your dependents have any other insurance coverage (including Florida Blue plans) that will
be in effect after this
coverage begins?
c
Yes
c
No
Sectio
n
E
: Other Health
Insurance
Information
This section must be completed for claims processing
and Prior Coverage
Information
Prior Health Carrier Name:
Complete the following only if this is the first time you or your dependents: (1) are enrolling for health insurance with this
employer; (2) currently have health
coverage; and/or (3) have any health coverage in the past 12 months that this coverage replaces OR you can attach a Certificate
of Creditable Coverage.
Contract #:
Effective Date:
I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Signature:
Date:
