Group Health Plan Enrollment Form

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Group Health Plan Enrollment Form
Division of Retirement and Benefits
P.O. Box 110203
Juneau, Alaska 99811-0203
Phone: Juneau—(907) 465-8600
FAX: (907) 465-4668 or TDD: (907) 465-2805
PERSONAL DATA
Employee Last Name
First Name
M.I.
Social Security Number
Are you covered by a health plan OTHER than the State Group or SBS plans?
No
Yes. Name of Carrier ___________________________
DEPENDENT INFORMATION
I HAVE NO ELIGIBLE DEPENDENTS
MY ELIGIBLE DEPENDENTS ARE LISTED BELOW
(Skip to Certification at Bottom)
(Attach additional sheets if necessary)
Dependent Last Name
First Name
M.I.
Male
Female
Relationship
Date of Birth
Mailing Address (if different from employee's)
City and State
ZIP +4
Social Security Number
Full-time Student
Is this dependent covered by a health plan OTHER than the State plans?
No
Yes
No
Yes. Name of Carrier ____________________________________
Dependent Last Name
First Name
M.I.
Male
Female
Relationship
Date of Birth
Mailing Address (if different from employee's)
City and State
ZIP +4
Social Security Number
Full-time Student
Is this dependent covered by a health plan OTHER than the State plans?
No
Yes
No
Yes. Name of Carrier ____________________________________
Dependent Last Name
First Name
M.I.
Male
Female
Relationship
Date of Birth
Mailing Address (if different from employee's)
City and State
ZIP +4
Social Security Number
Full-time Student
Is this dependent covered by a health plan OTHER than the State plans?
No
Yes
No
Yes. Name of Carrier ____________________________________
Dependent Last Name
First Name
M.I.
Male
Female
Relationship
Date of Birth
Mailing Address (if different from employee's)
City and State
ZIP +4
Social Security Number
Full-time Student
Is this dependent covered by a health plan OTHER than the State plans?
No
Yes
No
Yes. Name of Carrier ____________________________________
CERTIFICATION AND SIGNATURE
I certify that the above information is true and correct to the best of my knowledge. I understand that making false statements for
the purpose of obtaining benefits is an offense punishable by law.
Employee Signature
Date
S:/Benefits/02-1853.p65/1 (Rev. 2/00)

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