Form Pgc-Wa Lg Enroll - Enrollment/change Of Status/waiver Form - 2016

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Enrollment/Change of Status/Waiver Form

P.O. Box 4327, Portland, OR 97208-4327, 800-878-4445,

Please complete all information on this form. This information is required to process your enrollment.

Group information

Employer group name: ____________________________________ Group number: _______________________________________ Date of hire: ____________________

Requested effective date: _________________________________ Eligibility waiting period start date: ____________________ Class/subgroup: _________________

❏

New enrollment

Open enrollment

Waiver of coverage (see section 4)

❏

Change in existing status

Reason for status change:* __________________________________________________________ Date of event: __________________

Subscriber ID number: _____________________________________ COBRA/state continuation: Start date: __________________ End date: _______________________

❏

Plan type:

Core

Open Option

Personal Option

Traditional Option

Choice

Providence Dental annual maximum $: _________

Deductible/Copay

❏

HSA ❏ Integrated Health Savings Account with HealthEquity

– I have read and agreed to the

HSA authorization

form.

Section 1 - Employee information

❏

Male

❏

Female Date of birth: _________________________ Social Security number: ________________________________

❏

Married

❏

Single

First name: ______________________________________________________________ Last name: _____________________________ Middle initial: ___________________

Street address: ___________________________________________________________ City: ________________________ State: _____________ Zip: ___________________

Mailing address (if different than above): __________________________________ City: ________________________ State: _____________ Zip: ___________________

Daytime phone: __________________________________________ Evening phone: ____________________________ Email address: _____________________________

Section 2 - Dependent enrollment information

(if waiving, see section 4)

Middle

Relationship

Add

Drop

First name

Last name

Social Security number

Date of birth

Gender

initial

to employee

* Reasons include: rehired eligible employee, marriage, divorce, death, adoption, dependent change (add or drop), address or name change, involuntary loss of other coverage, COBRA or state continuation.

(Dependents of Personal Option subscribers moving out of or back into the service area must use the Out-of-Area Dependent Enrollment Form. Contact customer service at the number listed above to obtain one.)

PGC-WA LG Enroll (11/16) Washington – Large

(Continued on other side)

ENR-061D