Looking for a Mississippi Legal Forms And Templates? Download it for free!

Enrollee Last Name:

First Name:

Enrollee SSN:

Section E: Dependents

Dependents to be Covered

Relation to

Social Security

Date of Birth

Address

Current Status

(if different from Enrollee)

Enrollee

Number

(Last Name, First Name, MI)

Employed

❑ Husband

❑ Yes

❑ Wife

❑ No

❑ Son

❑ Child under 26

❑ Daughter

❑ Disabled

❑ Son

❑ Child under 26

❑ Daughter

❑ Disabled

❑ Son

❑ Child under 26

❑ Daughter

❑ Disabled

❑ Son

❑ Child under 26

❑ Daughter

❑ Disabled

Are any of the dependents listed above covered by Medicare Part A or Part B?

 No

 Yes If Yes, please provide the

following information:

NAME

Medicare Number

Part A Effective Date

Part B Effective Date

Medicare Reason

_______________________

______________________

___________________

______________________

_______________________

______________________

___________________

______________________

_______________________

______________________

___________________

______________________

Section F: Change Information

 Add Enrollee:  Open Enrollment  Marriage  Loss of Coverage due to Divorce  Birth  Adoption

Requested Effective Add Date _________________________________

 Other __________________________

 Add Dependent(s):  Open Enrollment  Marriage  Birth  Adoption  Other _______________________________

Requested Effective Add Date__________________________________

IMPORTANT: List all dependents to be covered in Section E.

 Change Coverage Option to:

 Base Coverage (HIGH DEDUCTIBLE)

 Select Coverage

 Drop Dependent(s):  Divorce  Deceased  Other______________________________________________

List all dependents to be dropped and provide the requested information in the spaces below:

NAME

SOCIAL SECURITY NUMBER

REQUESTED TERMINATION DATE

_________________________________________

_________________________

_____________________________________________

_________________________________________

_________________________

_____________________________________________

_________________________________________

_________________________

_____________________________________________

_________________________________________

_________________________

_____________________________________________

 Other Changes (Explain):

FOR EMPLOYER / ADMINISTRATOR USE ONLY:

GROUP NUMBER:___________________________

❑ New Legacy Employee, Requested Effective Date _____________________________________________

ENTERED BY: __________________

❑ New Horizon Employee, Requested Effective Date _____________________________________________

DATE: _________________________

❑ Retiree, Requested Effective Date ___________________________________________________________

❑ COBRA, Requested Effective Date ___________________________________________________________

VERIFIED BY: ___________________

❑ Surviving Spouse, Requested Effective Date __________________________________________________

DATE: __________________________

❑ Change(s), Requested Effective Date _________________________________________________________

Mississippi State and School Employees’ Health Insurance Plan

Health1 (6/12)

Application For Coverage Form - Mississippi State And School Employees' Health Insurance Plan Page 2

Related Articles

Related forms

Related Categories