Fillable Dental, Vision, And Cash-In-Lieu Enrollment/change Form printable pdf download

Effective Date:

City of Pomona

Dental, Vision, and Cash-In-Lieu

Enrollment/Change Form

Instructions: This form is used to enroll or to elect changes to dental, vision, or the Cash-In-Lieu Program. Complete the Employee Information

section for all actions. Review the sections titled Dental, Vision and Cash-in-Lieu. Select boxes below to indicate your request/change. When

adding or deleting a family member, the following documentation is required.

Marriage/Domestic Partner: Submit copy of marriage certificate or

Divorce: Must provide copy of Dissolution of Marriage.

egistered Domestic Partnership certificate.

Birth of a Child: Submit documentation of birth from hospital. Must

Cash-In-Lieu: Proof of other medical coverage (i.e. ID card)

submit a copy of birth certificate within 60 days of effective date.

EMPLOYEE INFORMATION

Employee Name ______________________________________

Social Security # _____________ Employee ID# _____________

Address _________________________________________________

Date of Birth _____________

_________________________________________________

E-Mail Address ______________________________________

Home Phone No. __________________ Mobile Phone No. ______________________ Work Phone No. _______________________

Married:

Yes. If yes, married to another City of Pomona employee?

Yes, Name: __________________________

DENTAL PLANS

New enrollment

Add family Member(s)

Delete family Member(s)

Change Plans

Delta Dental Mark one box, indicate plan coverage:

Single coverage

Two-party coverage

Family coverage

DHS *

Mark one box, indicate plan coverage:

Single coverage

Two-party coverage

Family coverage

* ___________________________/______________________

*DHS Provider

ID#

VISION PLAN

New enrollment

Add family Member(s)

Delete family Member(s)

EyeMed

Mark one box, indicate plan coverage:

Single coverage

Two-party coverage

Family coverage

DEPENDENTS – In the table below list all eligible dependents that you elect to enroll in your dental and/or vision plan. Under the Dental

column mark A to Add or D to Delete from the plan. Under the Vision column mark A to Add or D to Delete.

List all eligible dependents that you elect to enroll in your dental and vision plan

Dental Column

Vision Column

Action Code

Name

Relationship

Birth Date

A = Add

D = Delete

CASH IN LIEU PROGRAM - I certify that I am covered by another medical plan. I certify that I will maintain coverage in the alternative medical

p lan on an ongoing basis and I agree to notify the Human Resources Department immediately if I lose coverage.

Enroll in Cash in Lieu of Medical

Alternate Coverage _____________________

Cancel Cash in Lieu of Medical

Comments:_________________________________________________________________________________________________________

I hereby request coverage and authorize payroll deductions (if applicable) from my earnings for any contributions required for a minimum of one

year and while the programs are in force and I agree to comply with the terms of the group contract.

For HR Staff Use Only:

I agree to the terms and conditions of the plans I am choosing to enroll in or to make changes.

 Copy to Payroll ___________

 Vision Entry _____________

Printed Signature: ____________________________________

Date: _________________

 Dental Entry _____________

 Marriage or Dom Part Cert Rcv’d

 Dissolution of Marriage Received

Dental, Vision, And Cash-In-Lieu Enrollment/change Form

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