Address Change And Other Address/addressee Information Form - State Employees' Group Insurance Program
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1State Employees' Group Insurance Program
Address Change and Other Address/Addressee Information
Member Name:
_______________________________________
Primary Phone#:
_____________________
Member SSN:
_______________________________________
Alternate Phone #:
_____________________
Email Address: _________________________________
Complete Section A if:
You have moved or you want to change your mailing address to a P.O. Box. Note: Residential address
must be kept on file and must be your actual street address.
Your insurance information needs to be provided to an individual serving as your power of attorney, legal
guardian or trustee.*
Complete Section B if:
Your covered dependent does not reside with you.
Your covered dependent's insurance information needs to be provided to an individual serving as the
dependent's power of attorney, legal guardian or trustee.*
Your covered dependent is in the Veteran Adult Child category.
* You must provide the appropriate supporting documentation to add a power of attorney, legal guardian or trustee to
your insurance file.
SECTION A: MEMBER ADDRESS CHANGE or MEMBER'S "OTHER ADDRESSEE" INFORMATION
Complete this section if you moved, want to add a P.O. Box as your mailing address or if another person is
responsible for your healthcare and needs to be informed of your insurance information.
Mailing Address of:
Name ______________________________________________________
(check one)
Street Address ______________________________________________
Member
City ___________________________________
Trustee
State _____________
Zip ____________
County ____________________
Power of Attorney
If foreign address, indicate Country _________________________________
Legal Guardian
Effective Date ____________________
In Care Of
Mail to this address:
YES
NO
SECTION B: DEPENDENT RESIDENTIAL or DEPENDENT'S "OTHER ADDRESSEE" INFORMATION
Complete this section if another person needs to be notified of your dependent's insurance information, if your
covered dependent does not reside with you or if your dependent is covered as a Veteran Adult Child.
Dependent's Name: ___________________________________ Dependent SSN: ____________________
Mailing Address of:
Name _______________________________________________________
(check one)
Street Address _______________________________________________
Dependent
City ___________________________________
Custodial Parent
State _____________
Zip ____________
County ____________________
Trustee
If foreign address, indicate Country _________________________________
Power of Attorney
Effective Date ____________________
Legal Guardian
Veteran Adult Child
Mail to this address:
YES
NO
In Care Of
I understand that it is my responsibility to maintain correct mailing address information for dependents and/or
custodial parents. I understand that I must notify my GIR of any change in address information.
Member Signature: ________________________________________
Date: ________________________
THIS FORM MUST BE RETURNED TO THE GROUP INSURANCE REPRESENTATIVE AT YOUR AGENCY
CMS-314
(IL 401-1600)
02/12
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