Group Medical & Dental Insurance Form

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YESHIVA UNIVERSITY GROUP MEDICAL & DENTAL INSURANCE
First Name ______________________________________
MI ______Last Name ______________________________
Social Security Number ___________________________
Date of Birth _______________
Gender _______________
Home Address __________________________________________ City ______________________ST _____ZIP_________
Home Phone _________________________________________
Work Phone ______________________________
Email
Marital
Date of
Address _______________________________________
Status
Single
Married
Marriage ___________
Do you want to:
Enroll for health insurance
Add or drop dependents
Wa Waive Medical
Pick a Plan:
Empire Prism EPO
Empire BlueCard PPO
Empire Total Blue Choice HDHP
Blue Priority Network
Coverage Levels:
Employee Only
Employee + 1
Employee + 2
Family
Dental benefits are provided through CIGNA:
Do you want to:
Enroll for dental insurance
Waive dental insurance
Change your coverage level
Plan Choices:
Cigna DPPO Plan
Cigna DHMO Plan
Coverage Levels:
Employee Only
Employee + 1
Employee + 2
Family
Check the appropriate column to ADD eligible dependents not currently covered and/or to DROP ineligible dependents.
Social Security
Sex
Add
Drop
Name
Relationship
DOB
Health
Dental
Number
M/F
I have read and agree to the conditions listed in the Health Insurance Election information page. I authorize deductions of the required
contributions on a pre-tax basis and request that my gross earnings be reduced as provided under Section 125 of the IRS Code.
If I enrolled in the Total Blue Choice HDHP, I understand that it is a High Deductible Health Plan and I have read the information
provided and understand that by enrolling in this plan I will be responsible to pay out of pocket for most services until I meet my
deductible and out of pocket maximum. I understand that this may result in me incurring significant out of pocket costs before the plan
pays anything for eligible services.
I understand that my elections can only be changed during the next annual open enrollment period or if I have a qualifying family status
changed as defined by the IRS. I understand that I must request such changes within 60 days of the qualifying event and that any change
in coverage and any required contribution will be effective as of the date of the event.
Signature_____________________________________________________________ Date_________________________

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