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STATE OF MISSISSIPPI STATE AND SCHOOL EMPLOYEES HEALTH (Coahoma Community College)

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Application for Coverage Mississippi State and School Employees’ Health Insurance Plan Health1 (1/17)
STATE OF MISSISSIPPI
STATE AND SCHOOL EMPLOYEES’ HEALTH INSURANCE PLAN
APPLICATION FOR COVERAGE
PLEASE PRINT
Section A: Enrollee Information (all fields are required)
Social Security Number
First Name
MI
Last Name
Home Address
City
State
Primary Telephone Number
Secondary Telephone Number
Personal Email Address
Marital Status
Single Married
Gender
Male Female
Date of Birth (mm/dd/yyyy)
Date of Employment/Retirement
Were you ever a full-time employee of a covered entity under the Plan prior to 1/1/2006? No (Horizon) Yes (Legacy)
If yes, please list your most recent (pre-1/1/06) employer and dates of employment: ________________________________________________________
_________________________________________________________________________________________________________________________________________
If married, is your spouse a Plan participant? Yes No If yes, Spouse Name and SSN: ________________________________________________
Section B: Health Insurance Membership Agreement Authorization (CHECK ONLY ONE BOX, SIGN AND DATE)
I hereby apply to ADD, CONTINUE AND/OR CHANGE COVERAGE for myself and/or my dependents named on this Application For
Coverage form through the State and School Employees' Health Insurance Plan (PLAN). I certify that all information provided by me on this
application is complete and accurate, and is the basis for providing coverage herein. I understand that any misrepresentation by me or my
dependents may result in the cancellation of my/our coverage under the PLAN. I understand that the coverage applied for is subject to all
exclusions, provisions, and limitations set forth by the Plan Document. I agree to be bound by all terms and conditions of the PLAN. I understand
and agree that if my application for coverage is approved, any requested coverage changes will be effective the date fixed by the PLAN or
its Administrator. I understand that if the requested coverage is approved, I am responsible for payment of the appropriate premiums and
hereby authorize for such payments to be payroll deducted, or as appropriate, withheld from my State of Mississippi retirement benefits.
I hereby WAIVE COVERAGE in the State and School Employees’ Health Insurance Plan. I have been offered coverage (or am eligible for
continuation of coverage) through the PLAN, but I elect not to be covered. I understand that by waiving coverage at this time, I may only
request coverage for myself or myself and eligible dependents at an Open Enrollment Period or during a Special Enrollment Period. I understand
that if I am a retiree and I waive coverage, I will not be allowed to re-enroll or have my coverage reinstated at a later date. If you are waiving
coverage because you are currently covered under another health insurance policy, please complete Section D.
Enrollee Signature: _________________________________________________________ Date: ______________________________________
Section C: Coverage
Enrollee Type:
Employee - Legacy
Employee - Horizon
Retiree
COBRA
Surviving Spouse
Coverage Type:
Enrollee Only
Enrollee + Spouse
Enrollee + Child
Enrollee + Children
Enrollee + Spouse & Child(ren)
Coverage Option:
(Choose Only One)
Select
Base (HIGH DEDUCTIBLE)
Do you have Medicare? Yes No
Medicare Number: ___________________________
“A
” Effective Date: _________________________
“B” Effective Date: _________________________
Reason for Entitlement:
Age ESRD Disability
Are you a tobacco user? Yes No If yes, are you interested in participating in the Plan’s free cessation program? Yes No
Section D: Other Coverage Information
Do any of the persons listed on this application have other health insurance coverage? Yes No
If yes, please provide the following:
Name of Individual Covered: 1.____________________ 2.____________________ 3.______________________ 4.___________________
Policyholder’s Name: _______________________ __________________________ __________________________ _______________________
Policyholder’s Date of Birth: _______________________ __________________________ __________________________ _______________________
Policyholder’s Insurance
Effective Date: _______________________ __________________________ __________________________ _______________________
Policy Number: _______________________ __________________________ __________________________ _______________________
Policyholder’s Employment
Status:
Insurance Company Name _______________________ __________________________ __________________________ _______________________
address & phone #: _______________________ __________________________ __________________________ _______________________
_______________________ __________________________ __________________________ _______________________
_______________________ __________________________ __________________________ _______________________
Coverage Type:
Employer Name
Active, Retiree or COBRA
Active, Retiree or COBRA Active, Retiree or COBRA Active, Retiree or COBRA
Group Non-Group Group Non-Group Group Non-Group Group Non-Group
Application for Coverage Mississippi State and School Employees’ Health Insurance Plan Health1 (1/17)
Enrollee Last Name:
First Name:
Enrollee SSN:
Section E: Dependents
Dependents to be Covered
(Last Name, First Name, MI)
Relation to
Enrollee
Social Security
Number
Date of Birth
(mm/dd/yyyy)
Address
(if different from Enrollee)
Current Status
1.
Spouse
Male
Female
Employed
?
2.
Son
Daughter
Child under 26
Disabled
3.
Son
Daughter
Child under 26
Disabled
4.
Son
Daughter
Child under 26
Disabled
Are any of the dependents listed above covered by Medicare Part A or Part B?
If yes, please provide the following:
Name Medicare Number Part A Effective Date Part B Effective Date Medicare Reason
_______________________ ______________________ ___________________ ___________________ _____________________
_______________________ ______________________ ___________________ ___________________ _____________________
_______________________ ______________________ ___________________ ___________________ _____________________
Section F: Change Information
Add Enrollee: Open Enrollment Marriage Birth Adoption Loss of Coverage due to Divorce
Add Enrollee: Other: _______________________________ Requested Effective Date: _________________________________
Add Dependent(s): Open Enrollment Marriage Birth Adoption Other: ____________________________________
(List all dependents in Section E.) Qualifying Event/ Effective Date: ___________________________
Change Coverage: Base Coverage Select Coverage
Drop Dependent(s): Divorce Deceased Other: ________________________________________________________________
Provide information below for dependents to be dropped:
Name Social Security Number Requested Termination Date
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
Other Changes (Explain):
FOR EMPLOYER / ADMINISTRATOR USE ONLY: GROUP NUMBER:___________________________
New Legacy Employee, Requested Effective Date: _____________________________________________
New Horizon Employee, Requested Effective Date: _____________________________________________
Retiree, Requested Effective Date: ____________________________________________________________
COBRA, Requested Effective Date: ___________________________________________________________
Surviving Spouse, Requested Effective Date: ___________________________________________________
Change(s), Requested Effective Date: _________________________________________________________
ENTERED BY: __________________
DATE: _________________________
VERIFIED BY: ___________________
DATE: __________________________
Yes
No
Yes No
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STATE OF MISSISSIPPI STATE AND SCHOOL EMPLOYEES HEALTH (Coahoma Community College)

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Completed 19 September 2020

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