Option Period Enrollment/change Form For Current Employee - 2016
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1
2*OP2016*
Office of Management and Enterprise Services Employees Group Insurance Department
2016 OPTION PERIOD ENROLLMENT/CHANGE FORM
CURRENT EMPLOYEE
THIS FORM MUST BE RETURNED TO YOUR INSURANCE COORDINATOR
SECTION A: EMPLOYEE INFORMATION (Please Print)
Group ID# __________________________ Division ID# ________________ Group Name __________________________________
Member Name _____________________________________________________ SSN or Member ID# ________________________
First Name
MI
Last Name
Gender
Male
Female
________/_____ /__________
Married
Single
Birth Date
Mailing Address ______________________________________________________
Phone (______) _________-_____________
New Address
Alt Phone (______) ________-___________
____________________________________________________________________
City
State
ZIP Code
Email Address _________________________________________________________
SECTION B: ALL CHANGES ARE EFFECTIVE JAN. 1, 2016
See back side of form for required signatures and enrollment or change to dependent coverage.
Health Plan
HealthChoice High* or High Alternative (refer to Option Period materials)
To ADD or CHANGE
HealthChoice Basic* or Basic Alternative (refer to Option Period materials)
Plans, check a box to
HealthChoice High Deductible Health Plan (HDHP)
the right:
HealthChoice USA
*Requires completion of tobacco-free Attestation or Reasonable Alternative.
No Change
Aetna INTEGRIS HMO
CommunityCare HMO
Drop All Health
BlueLincs HMO
GlobalHealth HMO
Employee Primary Physician (HMO Plans Only) _____________________________________
New Patient
Current Patient
___________________________________________________________________________________________________________________
Dental Plan
Assurant Freedom Preferred
Assurant Heritage Plus w/SBA (Prepaid)
To ADD or CHANGE plans,
Assurant Heritage Secure (Prepaid)
check a box to the right:
CIGNA Dental Care Plan (Prepaid)
Delta Dental PPO
___________________________
No Change
Delta Dental PPO – Choice
Employee Primary Dentist
Drop All Dental
Delta Dental PPO Plus Premier
(Prepaid Plans Only)
HealthChoice Dental Plan
New Patient
Current Patient
___________________________________________________________________________________________________________________
Vision Plan
To ADD or CHANGE plans,
Humana Vision Care Plan
UnitedHealthcare Vision
check a box to the right:
Primary Vision Care Services
Vision Care Direct
Superior Vision
Vision Service Plan
No Change
Drop All Vision
___________________________________________________________________________________________________________________
Employee Life Plan
Dependent Life Plan (Employee Life Required)
Employee life CANNOT be added or increased using this form.
No Change
A separate “Life Insurance Application” must be completed and
Drop Dependent Life
approved to add or increase life insurance coverage.
Add or Increase to Premier Option
Add or Increase/Decrease to Standard Option
No Change
Drop All Life Insurance
Add or Decrease to Low Option
FOR IC USE ONLY
FOR EGID USE ONLY
Decrease total life insurance to: $ _____________
(Keep employee life in $20,000 units)
I have added or made changes on the back of this
form for my dependents.
Revised 08/25/2015
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