Employee Benefit Enrollment Application Form - Department Of Insurance & Risk Management - 2016 Page 2
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1
2IS YOUR SPOUSE/DOMESTIC PARTNER EMPLOYED?
Y
N
IF “YES” , PLEASE GIVE NAME AND ADDRESS OF THEIR EMPLOYER
OTHER INSURANCE
ADDRESS
AGENCY NAME
WILL YOU, YOUR SPOUSE/DOMESTIC PARTNER, OR YOUR DEPENDENTS BE COVERED BY SOME OTHER TYPE OF HEALTH INSURANCE WHILE COVERED UNDER SUMMIT COUNTY INSURANCE BENEFITS?
IF “YES” PLEASE COMPLETE THE FOLLOWING INFORMATION
REGULAR
COBRA
IF “YES” , START DATE ____________________ END DATE ______________
INSURANCE COMPANY NAME & ADDRESS
COVERED PERSON
ID #
GROUP #
COVERAGE TYPE
MEDICAL
VISION
DENTAL
OTHER
BENEFICIARY INFORMATION - COUNTY PAID LIFE: ANTHEM LIFE
LAST NAME
FIRST NAME
M I
RELATIONSHIP
BENEFICIARY
%
(SPOUSE/CHILD/OTHER)
(Primary or Secondary)
PRIMARY
SECONDARY
PRIMARY
SECONDARY
I hereby apply for the coverage indicated above. I authorize my employer/organization to deduct from my pay and remit any required
contribution for the cost of said coverage. I authorize any medical professional, hospital, clinic, or medically related facility, government
agency, other person to provide to the carrier information including copies of records concerning advice, care or treatment provided to
me and/or my dependents including, without limitation, information relating to mental illness or use of drugs or alcohol. I understand
that the kind of coverage for which I am making application contains coordination of benefits, workers’ compensation, and subrogation
provisions and acknowledge the carrier’s right to enforce these provisions. I have read the above statements and represent that the
information provided is true and complete to the best of my knowledge. I understand that the provision of any false information on
this application may result in the termination of my benefits and may subject me to legal action by the carrier or Summit County. I
understand that I may not change my elections, except during the annual enrollment period, unless I have a qualified change in status
(life event), as defined by the IRS. I understand I must notify the county within 30 days of occurrence of those changes in status. I
understand that if I am not actively at work on the date my coverage would otherwise become effective, my insurance will not begin
until the day I return to work.
APPLICANT’S SIGNATURE _________________________________________________________________ DATE ________________________
WAIVER
I hereby waive coverage under the County of Summit medical and prescription program and apply for the cash option.
Employees must provide proof of non-county insurance benefits to receive the cash option.
APPLICANT’S SIGNATURE _________________________________________________________________ DATE ________________________
EMPLOYER USE ONLY
COVERAGE EFFECTIVE DATE ______________________
PAYROLL ID (PIDM) _______________________________
ORG CODE _____________________________________
ANNUAL SALARY ________________________________
UNION LOCAL ___________________________________
WARNING: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
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REV. 1.16
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