Dual Option 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 _________________
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New enrollment
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Open enrollment
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Waiver of coverage (see section 4)
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Change in existing status Reason for status change* _____________________________________________________________Date of event ___________________
Subscriber ID number ______________________________ COBRA/state continuation: Start date ________________________ End date _______________________
Plan selection:
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Base Plan
_______________
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Buy-up Plan
Deductible: $
Deductible: $ ___________________
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Plan type:
Core
Open Option
Personal Option
Traditional
Choice
Connect
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HSA
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Integrated Health Savings Account with HealthEquity® – I have read and agreed to the HSA authorization form.
Section 1 - Employee information
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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-OR LG Dual Option Enroll (01/15) Oregon – Large
(Continued on other side)
ENR-064B
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