Fillable Reinstatement Loss of Coverage Marriage Birth (Warrick County Commissioners)

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Reinstatement Loss of Coverage Marriage Birth (Warrick County Commissioners)

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U.S.A. forms for Warrick County Commissioners

BROWSE WARRICK COUNTY COMMISSIONERS (IN) FORMS

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COMPANY NAME: GROUP #:
BENEFIT ENROLLMENT FORM
154.762017
EMPLOYER USE ONLY
DATE OF HIRE
EFFECTIVE DATE
DIVISION #
DEPT. # / CLOCK #
ANNUAL SALARY: $
□ HOURLY □ SALARY
□
NEW ENROLLMENT
□ Active □ Retiree
□ Full Time □ Part Time
□ COBRA
□
ENROLLMENT CHANGE
□ Marriage □ Birth □
Adoption
□ Reinstatement □ Loss of Coverage
□ Other:
Employer Representative Signature:
Date:
THIS FORM IS TO BE COMPLETED FOR NEW ENROLLMENTS AND COVERAGE CHANGES
PLEASE PRINT CLEARLY AND COMPLETE THE ENTIRE FORM
(ALL INFORMATION MUST BE COMPLETED OR ENROLLMENT WILL BE DELAYED)
EMPLOYEE INFORMATION – ALL INFORMATION IS REQUIRED
LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NO.
(MM/DD/YY)
GENDER
□
M
□
F
MARITAL STATUS
□
Single
□
Married
□
Divorced
□
Widowed
MAILING ADDRESS
CITY
STATE
ZIP
HOME PHONE NUMBER
WORK PHONE NUMBER
ARE YOU THE EMPLOYEE COVERED UNDER ANY OTHER INSURANCE? YES NO (i.e. Medicare, Tricare, spouse’s plan)
IF YES, NAME OF INSURANCE: EFFECTIVE DATE:
TYPE OF POLICY (Retiree, COBRA, Spouse): POLICY HOLDER (Self, Spouse):
IF ENROLLED IN MEDICARE: EFFECTIVE DATE: PART A PART B HICN
ENTITLEMENT TO MEDICARE DUE TO: □ AGE □ DISABILITY □ END STAGE RENAL DISEASE (ESRD)
BENEFIT SELECTION
COVERAGE TYPE
PLAN ELECTED
COVERAGE LEVEL
MEDICAL/RX
HDHP PLAN
POS PLAN
SINGLE EMPLOYEE + SPOUSE EMPLOYEE + CHILD FAMILY
DECLINE
DEPENDENT INFORMATION (ALL INFORMATION MUST BE COMPLETED OR ENROLLMENT WILL BE DELAYED)
Special Enrollment due to coverage under Medicaid or under a State Children's Health Insurance Program (CHIP). If an employee or eligible dependent did not enroll in the plan
when initially eligible, he or she will be permitted to later enroll in the plan under one of the following circumstances:
a. The employee or eligible dependent loses their eligibility status to participate in Medicaid or CHIP; or
b. The employee or eligible dependent qualifies for premium assistance under Medicaid or CHIP at the state level in which the individual resides.
The employee or eligible dependent must request enrollment in the plan within 60 days after coverage under Medicaid or CHIP terminates or within 60 days of being notified of eligibility
for premium assistance from the state in which the individual resides.
DEPENDENT FULL NAME (REQUIRED)
(LAST, FIRST, MIDDLE)
SOCIAL SECURITY NO.
(REQUIRED)
RELATIONSHIP
(REQUIRED)
DATE OF BIRTH
(MM/DD/YY)
GENDER
(M/F)
CHECK COVERAGE
DISABLED
DEPENDENT*
MEDICAL/RX
YES
NO
MEDICAL/RX
YES
NO
MEDICAL/RX
YES
NO
MEDICAL/RX
YES
NO
MEDICAL/RX
YES
NO
*IF YOUR CHILD IS MENTALLY OR PHYSICALLY DISABLED, PLEASE PROVIDE APPROPRIATE DOCUMENTATION
Warrick County Government
16245
154.762017
COMPANY NAME:
COORDINATION OF BENEFITS – SPOUSE INFORMATION (IF APPLICABLE) COMPLETE ALL QUESTIONS
IS YOUR SPOUSE EMPLOYED? YES NO IF YES, FULL TIME PART TIME SPOUSE EMPLOYER NAME: SPOUSE DATE OF BIRTH:
INDICATE THE COVERAGE, CARRIER NAME AND EFFECTIVE DATE THAT YOUR SPOUSE IS ENROLLED IN WITH HIS/HER EMPLOYER
TYPE OF OTHER
COVERAGE
CARRIER NAME CARRIER ADDRESS
EFFECTIVE DATE
(MM/DD/YY)
TYPE OF POLICY (I.E. EMPLOYER,
RETIREE, COBRA)
LIST ALL FAMILY MEMBERS
ENROLLED IN THIS PLAN
MEDICAL
PRESCRIPTION
DENTAL
VISION
COORDINATION OF BENEFITS – DEPENDENT CHILD(REN) INFORMATION (IF APPLICABLE) COMPLETE ALL QUESTIONS
ARE ANY OF YOUR DEPENDENT CHILD(REN) COVERED BY ANOTHER PARENT/GUARDIAN OR PLAN NOT LISTED ABOVE? YES NO
EMPLOYER PROVIDING COVERAGE:
IF YES, COMPLETE THE QUESTIONS BELOW
TYPE OF OTHER
COVERAGE
CARRIER NAME CARRIER ADDRESS
EFFECTIVE
DATE
(MM/DD/YY)
TYPE OF POLICY
(I.E. EMPLOYER,
RETIREE, COBRA)
COURT ORDER REQUIRING
COVERAGE (I.E. DIVORCE
DECREE, QMCSO)*
LIST ALL FAMILY MEMBERS
ENROLLED IN THIS PLAN
MEDICAL
PRESCRIPTION
DENTAL
VISION
*COPY OF THE COURT ORDER MUST BE SUBMITTED. FAILURE TO DO SO WILL RESULT IN CLAIMS BEING DENIED.
COORDINATION OF BENEFITS – GOVERNMENTAL INSURANCE (I.E. MEDICARE, MEDICAID,TRICARE, ETC.)
IS YOUR SPOUSE AND/OR ARE ANY DEPENDENTS ENROLLED IN ANY GOVERNMENTAL INSURANCE? YES NO IF YES, PLEASE COMPLETE BELOW
LIST ALL FAMILY
MEMBERS ENROLLED
TYPE OF
COVERAGE
EFFECTIVE DATE OR IF MEDICARE
COVERAGE, PART A EFFECTIVE DATE
PART B EFFECTIVE DATE
(IF APPLICABLE)
HICN
IS MEDICARE
COVERAGE DUE TO:
AGE
DISABILITY
ESRD
AGE
DISABILITY
ESRD
PLAN DECLARATION
I understand that the above elections will remain in effect until the last day of the Plan Year for which they are effective and will continue in effect indefinitely beyond that Plan Year
unless I make an election change permitted under the Plan. I understand that I may change my elections during the Plan Year only if (i) I experience a “status change”, as defined
under the Plan, and if my change in elections is consistent with that “status change”, (ii) I exercise a Special Enrollment Period Right (as described in the Notice of Special Enrollment
Periods below), or (iii) I qualify (under applicable law, as determined by the Plan Administrator) to make another election change because of certain changes in cost or coverage of a
benefit option, or for certain other reasons. I understand that the cost of a benefit option that I have elected under the Plan may change from one Plan Year to the next and I hereby
agree that my payroll deductions will automatically change accordingly unless I submit a new Election Form during the appropriate annual election period to change or terminate that
coverage. I also understand, during a Plan Year, if there is a change in the cost of a benefit option that I have elected, the Employer may automatically increase the payroll deductions,
if any, I am required to make per pay period to pay for that benefit option. I understand further that, except to the extent that I am permitted to make a change under the Plan, the
payroll deduction elections I have made above will continue in effect notwithstanding any changes in the features or coverage offered under the benefit options I have elected above.
I understand that my employer may modify my benefit elections if appropriate to insure that the Plan complies with the terms of the Plan and the requirements (including tax-
qualification requirements) of applicable law and that, subject to the requirements of applicable law or any applicable insurance contract, my employer retains the right to amend or
terminate coverage under a benefit option. Also, I understand that the employer may modify my elections for health benefit options if required to do so by a Qualified Medical Child
Support Order that requires me to provide health coverage for a dependent.
NOTICE OF SPECIAL ENROLLMENT PERIODS
If you are declining enrollment in the Plan’s health coverage options for yourself or your dependents (including your spouse) because of other health insurance or group health plan
coverage, you may be able to enroll yourself and your dependents in the Plan’s health coverage features if you or your dependents lose eligibility for that coverage (or if the employer
stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or
after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you
must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
To request special enrollment or obtain more information, contact your Human Resources representative.
SIGNATURE AND AUTHORIZATION
EMPLOYEE SIGNATURE
PRINT EMPLOYEE NAME
DATE
Warrick County Government
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Reinstatement Loss of Coverage Marriage Birth (Warrick County Commissioners)

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Completed 18 July 2020

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