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Employee Enrollment And Change Form

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12401 E. Marginal Way S., Tukwila, WA 98168

Employee enrollment and change form

P.O. Box 34750, Seattle, WA 98124-9745

EMPLOYER: PLEASE COMPLETE THIS SECTION.

Original date of hire

___ / ___ / ___

Choose one:

Transfer to COBRA

Coverage effective date _______________________

Date of rehire

___ / ___ / ___

Open enrollment

Add dependent(s)

Start date ____ / ____ / ____

New employee

18 months

Date transferred from part time

Remove coverage

Group name _________________________________

(p/t) to full time (f/t)

___ / ___ / ___

Address/name

Subscriber

36 months

change

Dependent(s)

Group number __________________________________

Hours worked per week

_____________

Qualifying event __________________

Pay location (if applicable) ________________________

If retired, date of retirement ___ / ___ / ___

Date processed ____ / ____ / ____ by _______

EMPLOYEE: COMPLETE THE FOLLOWING. PLEASE PRINT.

Employee name _____________________________________________________________________________________________

Work phone (

) ________________________

(Last name)

(First name)

(M.I.)

Resident address _________________________________________________________________________________________________

Home phone (

) ________________________

(Street)

(City)

(State)

(ZIP)

Mailing address (if different) ______________________________________________________________________________________

E-mail address

* _______________________________

* By providing your e-mail address, you are agreeing to

Former name of applicant or spouse (if applicable) __________________________________________________________________

receive e-mail communications from Group Health.

Selected health plan: __________________________________________________________________________________________

Check one

For health plan internal

Please print

Social Security number

Male/

Birthdate

Relationship

use only

(required)

Female

(MM/DD/YY)

to employee

Last name

First name

M.I.

Add

Remove

Self

Spouse/domestic partner/dependent (circle one)

Dependent

I would like to become a voting member of Group Health Cooperative.

_____________________________________________________________________________________________

My eligible dependents (age 18 and older) would like to become

voting members of Group Health Cooperative.

(Signature of employee)

(Date signed)

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines,

and denial of insurance benefits.

15-XLOB-1188-03

Coverage provided by Group Health Cooperative, registered in Washington state, or Group Health Options, Inc., registered in Washington and Idaho.