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STATE OF MISSISSIPPI

STATE AND SCHOOL EMPLOYEES’ HEALTH INSURANCE PLAN

APPLICATION FOR COVERAGE

PLEASE PRINT

Section A: Enrollee Information (all fields are required)

Social Security Number

First Name

Last Name

Home Address

City

State

ZIP

Primary Telephone Number

Secondary Telephone Number

Email Address

Marital Status

Sex

Date of Birth

Date of Employment/Retirement

(MMDDYYYY)

❑ Single

❑ Married

❑ Male

❑ Female

Were you ever a full-time employee of a covered entity under the State and School Employees’ Health Insurance Plan (PLAN)

prior to 1/1/2006?  No (Horizon)  Yes (Legacy)

If Yes, please list your most recent (pre-1/1/06) employer and dates of

employment: _______________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

If married, is your spouse a participant in the PLAN?

 Yes

 No

If Yes, please provide your spouse’s name and Social Security Number:_____________________________________________________

Section B: Health Insurance Membership Agreement Authorization (CHECK ONLY ONE BOX, SIGN AND DATE)



I hereby apply to ADD, CONTINUE AND/OR CHANGE COVERAGE for myself and/or my dependents named on this Application For Coverage

form through the State and School Employees' Health Insurance Plan (PLAN). I certify that all information provided by me on this application is

complete and accurate, and is the basis for providing coverage herein. I understand that any misrepresentation by me or my dependents may

result in the cancellation of my/our coverage under the PLAN. I understand that the coverage applied for is subject to all exclusions, provisions,

and limitations set forth by the Plan Document. I agree to be bound by all terms and conditions of the PLAN. I understand and agree that if my

application for coverage is approved, any requested coverage changes will be effective the date fixed by the PLAN or its Administrator. I

understand that if the requested coverage is approved, I am responsible for payment of the appropriate premiums and hereby authorize for

such payments to be payroll deducted, or as appropriate, withheld from my State of Mississippi retirement benefits.



I hereby WAIVE COVERAGE in the State and School Employees’ Health Insurance Plan. I have been offered coverage (or am eligible for

continuation of coverage) through the PLAN, but I elect not to be covered. I understand that by waiving coverage at this time, I may only

request coverage for myself or myself and eligible dependents at an Open Enrollment Period or during a Special Enrollment Period. I understand

that if I am a retiree and I waive coverage, I will not be allowed to re-enroll or have my coverage reinstated at a later date. If you are waiving

coverage because you are currently covered under another health insurance plan, please complete Section D.

Enrollee Signature ______________________________________________________

Date ___________________________________

Section C: Coverage

Enrollee Type:

Coverage Type:

Coverage Option

❑

Do you have Medicare?

Yes

(Choose Only One)

❑

Employee - Legacy

Enrollee Only

Medicare Number ______________________________

❑

Employee - Horizon

Enrollee + Spouse

❑ Select

“A” Effective Date ____________________________

❑

Retiree

Enrollee + Child

❑

“B” Effective Date ____________________________

❑

COBRA

Enrollee + Children

Reason for Entitlement:

❑ Base (

)

HIGH DEDUCTIBLE

❑

Surviving Spouse

Enrollee + Spouse & Child(ren)

❑

Age

ESRD

Disability

Section D: Other Coverage Information

Do any of the persons listed on this application have other health insurance coverage?

 No

 Yes If Yes, please provide

the following information:

1.____________________

2.____________________

3. ___________________

4. ___________________

Name of Individual Covered:

Policyholder’s Name:

_______________________

Policyholder’s Date of Birth:

_______________________

________________________

_______________________

Policy Number:

_______________________

________________________

_______________________

Policyholder’s Employment

Status (Circle):

Active, Retiree or COBRA

Insurance Company Name

_______________________

_________________________

_______________________

address & phone #:

_______________________

_________________________

_______________________

_________________________

_______________________

_________________________

_______________________

Coverage Type (Circle):

Group or Non-Group

Mississippi State and School Employees’ Health Insurance Plan

Health1 (6/12)

Application For Coverage Form - Mississippi State And School Employees' Health Insurance Plan

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