Form Sb.ee.10.va - Employee Enrollment Form

Form Sb.ee.10.va - Employee Enrollment Form - 2010 Page 2

Employee Name __________________________________________________________________________________________________________

B. Family Information

List All Enrolling (Attach sheet if necessary)

Tobacco

Last Name

First Name MI Sex Relationship***

Physician* (Name/ID#)

Birthdate

Height

Weight

Used

Social Security Number

Primary Care Dentist** (Name/ID#)

Spouse

Yes

[/Domestic

Partner]

Yes

Dependent

Yes

Dependent

Yes

Dependent

Yes

Dependent

***For court ordered dependent, legal documentation must be attached. If dependent does not reside with eligible employee, please provide

address on separate sheet.

D. Prior Medical Insurance Information

This section must be completed to receive credit for prior medical coverage.

Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage?

YES (if yes, please complete this section.)

Prior medical carrier name ____________________________________________________ Effective date ___/___/___ End date ___/___/___

Prior coverage type:

Employee

Spouse

Child(ren)

Family

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Form Sb.ee.10.va - Employee Enrollment Form - 2010 Page 2