Employee Life Insurance Form
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1
2THIS IS A FILLABLE FORM: PRINT WHEN COMPLETE: When Printing-mark fit to print
INSURANCE OFFICE USE ONLY
16
JORDAN SCHOOL DISTRICT EMPLOYEE BENEFIT CHANGE FORM
Year: 20___-____
15
PEHP CODE 1082._______
PLEASE REFER TO THE BENEFIT ENROLLMENT GUIDE FOR AN OVERVIEW OF BENEFITS.
Cobra (.1) Retiree (.3) LTD (.5) Dual (.8)
Qualifying Event (This form must be received within 30 calendar days of event date)
X ELIGIBLE=Eligible
NOTELIG=Not Eligilble
REASON
(If there is more than one member with a change and they have different Events or Event Dates,
FOR
You MUST complete a Separate form for each).
CHANGE:
Open Enrollment (June/July effective September)
____________________________________________________
A. EMPLOYEE INFORMATION (Please type or print clearly)
Hire Date:__________________ Member # _________________
LAST
FIRST
M.I.
NAME
NAME
Med End Date___________________
Old Plan ____________________
SOCIAL
BIRTH
GENDER
MARITAL
GENDER
Med Start Date __________________
New Plan ___________________
SECURTIY #
DATE
STATUS
Den End Date____________________
Old Plan ____________________
STREET
APT #
Den Start Date __________________
New Plan ___________________
ADDRESS
Vis End Date______________________
Old Plan ____________________
CITY
ST
ZIP
HOME
Vis Start Date ____________________
New Plan ___________________
PHONE
Medical
Dental
Vision
WORK
JOB
Plan
________________
________________
_______________
LOC
TITLE
Enrolled
E0 E1 E2 E3
E0 E1 E2 E3
E0 E1 E2 E3
Employee Classification: (choose one)
Employee Hours (Choose One)
Employee Status: (choose one)
(Eligible FT)
Licensed
Full Time
Basic Life
Active
☐Single
☐Family
(Eligible PT)
Classified
¾ Time
Retiree
Life Only Effective _______________________
(Eligible PT)
Administration
½ Time
LTD
☐
☐
Cigna:
LE LS LC AD&D
Aflac
TYPE OF CHANGE:
Enrolling
Change
Cancelling
O
O
Request Cert/LOE
Cert/LOE Received
DATE QUALIFYING EVENT TOOK PLACE: __________________
OO
OO
OO
Marr Cert
1040 Tax
Birth Certs
**Birth
**Divorce
Beneficiary Change
OO
OO
OO
Adoption
Divorce
Other
**Adoption
**Dependent Death
Voluntary Life Insurance Change
☐
☐
PEHP__________________
PD ____________________
***Employee Marriage
*Eligible for Other Coverage
AD&D Change
☐
☐
***Dependent Marriage
*Involuntary Loss of Coverage
*COB (Coordination of Benefits)
District ______________
ACA _________________
Increase/Decrease of Employee Hours
Other (Specify)
___________________________
☐
☐
LN ___________________
COB
*Certificate of Insurance required, when received
**Legal papers required
Verified: ☐Scan ☐Skyward ☐PEHP ☐ES
***Certificate of Insurance and legal papers required
B. EMPLOYEE AND DEPENDENT INFORMATION
Basic Life
LIST ALL ELIGIBLE FAMILY MEMBER(S)
Coverage Election/Waiver Per Individual:
District
Employee must be enrolled for dependent(s) to enroll. All must be on same plan as employee.
If enrolling Select Plan Choice in Section C
paid
MEDICAL
DENTAL
VISION
See Sec G.
Name Covered Member(s)
Sex
Birth Date
Relationship
Mark One
Mark One
Mark One
Mark Yes for all
Social Security #
AGE
eligible
Enroll /
Waive/
Enroll /
Waive/
Enroll /
Waive/
(Last, First, M.I.)
(M/F)
(MM/DD/YY)
dependents
Change
Cancel
Change
Cancel
Change
Cancel
Yes
No
Employee
Yes
No
Spouse
CHILD(REN)
Married Children are not eligible for Dental, Vision or Life Insurance
Step
Yes
No
Married
Step
Yes
No
Married
Step
Yes
No
Married
Step
Yes
No
Married
Step
Yes
No
Married
Step
Yes
No
Married
Step
Yes
No
Married
C. PLAN SELECTION: COMPLETE ONLY IF MAKING CHANGE IN SECTION B
MEDICAL (Choose One)
DENTAL (Choose One)
VISION:
TRADITIONAL PPO
VALUE
DENTAL SELECT
EMI
TDA
OPTICARE
***You must contact TDA
Advantage
Value Advantage
Silver
Option 1
Eclipse***
10-70
to select a provider or
10-120
Summit
Value Summit
Gold
Option 2
Total Care***
one will be assigned to
you.
Platinum
PPO
D. COORDINATION OF BENEFITS
*Certificate of Insurance required, when received
If you or another family member has acquired or is terming from any other medical insurance, including a spouse’s Jordan School District Medical plan, please complete the following:
Adding other Medical coverage information
Cancelling other Medical coverage information
Policy
Policy
Effective Date
Cancellation Date Policyholder Name (Last, First, M.I.)
Covered Members (Last, First, M.I.)
Name of other Insurance Company
nd
Basic and Voluntary Life and Beneficiary Enrollment is on 2
Page
Employee Must complete and sign Page 2 to be valid
Page 1 (Rev 4/15)
Now click down in Section G
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