Employee Change Application Form
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1
2Employee Change Application
Please type or write clearly in black or blue ink.
Section A: Current Information
Group Name:
Group #:
Division #:
Package #:
Seminole State College of Florida
31980
Employee Name: (Last, First Name, M.I.)
ocial Security #:
Effective Date of
Date of Event:
S
Coverage:
Section B: Coverage Change Information
Reason for
¨ Adoption
¨ Death
¨ L eave of Absence/Layoff
¨ Moved from Service Area
Change:
¨ Open Enrollment
¨ Section 125
¨ Marriage
¨ Birth
¨ O ver-Aged Dependent
¨ T erminate
¨ R eturn of Alternate
¨ Loss of Coverage
¨ Divorce
Employment
Insurance
¨ Plan Type:______________
¨ Location__________
¨ Employee #___________
(ex. PPO, HMO, RX)
Change
¨
New Name:
New Physician Name/ID:
Request Type:
¨
New Address:
New Phone #:
Plan Coverage Type Requested: ¨ Add Health ¨ Delete Health ¨ Add Vision ¨ Delete Vision
¨ Change Plan:
Indicate Plan #
Coverage Level Requested: ¨ Employee ¨*Employee & Spouse ¨*Employee & One Dependent ¨*Employee & Children ¨ Family
* When available
¨ Dependent Change
Complete Section C
¨ Other Change:
Applicable to Group Administrator: The Affordable Care Act prohibits rescissions; cancellations cannot be submitted for the period in
which a premium is collected. By submitting cancellation(s) you represent that you have not collected a premium from the employees/
dependents for coverage after the requested termination date.
Section C: Dependent Information
Attach separate sheet, if additional space is needed, with dependent information, sign and date.
List the name of each dependent listed above that is married or has dependent child(ren) or lives outside of Florida.
* If you indicated “O” in “Relation to You” above for any dependents, please explain here:
Section D: Other Health Insurance Information
and Prior Coverage Information
This section must be completed for claims processing
In addition to this policy, do you or your dependents have any other insurance coverage (including Florida Blue plans) that will be in
effect after this coverage begins? ¨ Yes ¨ No
Florida Blue Contract #___________________ Medicare #______________________ Pharmacy/Medicare D #_______________________
Complete the following only if this is the first time you or your dependents: (1) are enrolling for health insurance with this employer;
(2) currently have health coverage; and/or (3) have any health coverage in the past 12 months that this coverage replaces OR you can
attach a Certificate of Creditable Coverage. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Prior Health Carrier Name
Contract #:
Effective Date:
Prior Employee Hire Date:
Cancel Date:
List names of all family members that were covered, including
yourself:
Employee Signature:
Date:
Employer Signature:
Date:
22411-0813
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Parent category: Business