Kenyon College
UMR Health/Dental Enrollment or Change Form
Name: Last, First, M.I. Start Date or Change Date
Home Phone Home E-mail
Date of Birth
Last 4 digits of SSN Gender
Marital
Status
Current Home Address (If you are in the process of moving, please provide your address at this time, then provide an update to HR
once your new address is established). List Street Address, P.O. Box if applicable, City, State, Zip.
KC Health Insurance Plan -
Detailed
Eligibility, Rates and Plan information
Waive Coverage
Premium Plan
Basic Plan
Health Coverage Options if
you have selected
enrollment on the left
Employee Only
Employee + 1
Family (3 or more)
KC Dental Insurance Plan -
Detailed Eligibility, Rates and
Plan information
Waive Coverage
Employee Only
Employee + 1
Family (3 or more)
Add the names of the dependent(s)/spouse//partner you wish to enroll below:
Name
(First, MI, Last)
Social
Security # Gender Birth Date
Relation
Name
(First, MI, Last)
Social
Security # Gender Birth Date
Relation
Name
(First, MI, Last)
Social
Security # Gender Birth Date
Relation
Name
(First, MI, Last)
Social
Security # Gender Birth Date
Relation
Check this box if you or any of your dependents have other health or dental coverage that should be counted as primary.
Yes, I confirm that I have additional health or dental coverage and will provide insurance information to Human Resources
Enrollment selections on this most current form will supersede any previous enrollment selections.
*If you waive medical coverage, please add a brief decline reason above for ACA reporting.
__________________________________________________________________________
Signature Date
If your software does not allow for signatures, please type your initials here in lieu of a signature.
KC Vision Insurance Plan -
Detailed Eligibility, Rates
and Plan information
Waive Coverage
Employee Only
Employee + 1
Family (3 or more)
click to sign
signature
click to edit
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