Employee Enrollment Application - New Mexico

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Former Employer

Basic Life Eff. Date

Other Cvrg Eff. Date

MEDICAL

DENTAL

VISION

DISABILITY

ADDITIONAL LIFE

For Employer Use:

(if covered under NMPSIA)

(mm/dd/yyyy)

PAYROLL DEDUCTIONS

District/Entity Name

District/Entity #

New Mexico Public Schools Insurance Authority

EMPLOYEE ENROLLMENT APPLICATION

RESET FORM

Eligibility Administrative Office (505) 988-4974 (800) 233-3164 FAX (505) 988-8943

Social Security Number

Name

Date of Birth

(Last, First, Middle)

(mm/dd/yyyy)

Mailing Address

City

State

Zip Code

Home Phone Number

Marital Status

Gender

E-Mail Address

Work Phone Number

Cell Phone Number

By furnishing my e-mail address on this form, I am consenting to receive

communications related to my participation in NMPSIA’s benefit program by e-mail.

Check this box if you do not wish to receive plan communications by e-mail.

ENROLLMENT STATUS

Employee Only

2-Party (Employee + Spouse or Child)

Family (Employee + 2 or more)

ENROLLMENT

Elect your coverage offered by your employer

BASIC LIFE: The Standard (Paid in full by employer. Complete Schedule A Beneficiary Form)

MEDICAL:

Decline Medical. Reason for declining

Blue Cross Blue Shield NM (Default)

Presbyterian

New Mexico Health Connections

coverage:

High Option (Default)

Low Option

HMO Option

Are you eligible for Medicaid?

Yes

DENTAL: United Concordia

High Option (Default)

Low Option

Decline Dental

VISION: Davis Vision (2 year enrollment required)

Decline Vision

LONG TERM DISABILITY: The Standard

Decline Long Term Disability

ADDITIONAL LIFE:

The Standard

Select:

3X Base Annual Salary

Decline Employee Additional Life

(Complete Schedule A Beneficiary Form)

Spouse Life

Child Life

Decline Dependent Life

DEPENDENT INFORMATION

List employee and all dependents with SSN. Indicate an A (add) or N/A (not applicable) for each person listed.

Please provide requested information for additional dependents on separate sheet if necessary.

Dependent’s

Proof of Marriage,

Social Security

Add’l

Date of Birth

Med

Dntl

Visn

Dependent’s Name

Gender

Relationship to

Birth, or Court

(Last, First, Middle)

Number

Life

(mm/dd/yyyy)

You

Order Attached

(REQUIRED)

Yes

EMPLOYEE AUTHORIZATION STATEMENT

I hereby authorize my school district/employer to deduct from my earnings until further written notice, amounts equal to the contribution required of me toward the plan(s) herein enrolled. I hereby apply to the Authority

for the coverage offered to myself and dependents shown above. I understand that services will be available subject to the exclusions, limitations and the conditions described in the Master Group Insurance Policies.

I authorize any hospital, physician, or other health care provider to furnish (when applicable) to the Insurance Carrier such medical information as it may require for myself and my dependents. I authorize the

Insurance Carrier to coordinate benefits and/or reimbursements with other health plans or insurance companies. Under penalties of perjury and insurance fraud, I declare that I have examined this application and

supporting documentation, and to the best of my knowledge and belief, they are true, correct, and complete. Read reverse side before signing.

EMPLOYEE SIGNATURE

DATE

RETURN THIS FORM TO YOUR EMPLOYEE BENEFITS OFFICE NO LATER THAN 31 DAYS FROM YOUR DATE OF HIRE

EMPLOYER CERTIFICATION

ALL INFORMATION IN THIS SECTION IS REQUIRED TO DETERMINE ELIGIBILITY. PLEASE COMPLETE THIS SECTION THOROUGHLY.

I attest that to the best of my knowledge that this applicant is an employee of my district/entity (or meets the one-bus owner definition) and works the minimum number of hours per week required for NMPSIA benefits.

Date of Hire

Base Annual Salary

# of hours

Date Eligible

Job Title

Date Received in Your

(First day to report

(Do not include increments or stipends:

worked weekly

Variable hour, part-

for Benefits

Office