Option Period Enrollment/change Form For Current Employee

SECTION C: DEPENDENT COVERAGE

SPOUSE*

Add Drop

Health

Name

SSN

Dental

Date of Birth ___________________________________

Male

Female

Vision

Primary Physician _______________________________

New Patient

Current Patient

Dependent Life

Primary Dentist _________________________________

New Patient

Current Patient

* Does your spouse currently have coverage through EGID?

Yes

No (If yes, list name and SSN above)

CHILD

Add Drop

Health

Name

SSN

Dental

Date of Birth ___________________________________

Male

Female

Vision

Primary Physician _______________________________

New Patient

Current Patient

Dependent Life

Primary Dentist _________________________________

New Patient

Current Patient

CHILD

Add Drop

Health

Name

SSN

Dental

Date of Birth ___________________________________

Male

Female

Vision

Primary Physician _______________________________

New Patient

Current Patient

Dependent Life

Primary Dentist _________________________________

New Patient

Current Patient

CHILD

Add Drop

Health

Name

SSN

Dental

Date of Birth ___________________________________

Male

Female

Vision

Primary Physician _______________________________

New Patient

Current Patient

Dependent Life

Primary Dentist _________________________________

New Patient

Current Patient

PLEASE USE THE DEPENDENT ATTACHMENT FORM TO ADD MORE DEPENDENTS.

(This form is available from your insurance coordinator)

SECTION D: CERTIFICATION SIGNATURES

Employee Signature

__ Date

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YOUR SPOUSE MUST SIGN IF THEY ARE COMMON-LAW OR EXCLUDED FROM HEALTH AND/OR DENTAL

COVERAGE.

COMMON-LAW SPOUSE CERTIFICATION: I certify that the person listed as my spouse and I have an actual and mutual agreement between

ourselves to be married; that this is a permanent relationship, and that our relationship is exclusive, as proven by our cohabitation as spouses; and do

hereby hold ourselves out publicly as married. I am aware that this relationship can be dissolved only by legal divorce.

SPOUSE EXCLUSION CERTIFICATION (required only if children are covered and spouse is not): I certify that I am aware I am being excluded

from health and/or dental coverage as indicated on this form. I am also aware that an employee who elects to cover all eligible dependent children

and NOT their spouse will not have the opportunity to enroll their spouse until either the next annual Option Period or a change of status event occurs.

Spouse Signature

___ Date

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

I certify (if required) the employee is both living and working outside of Oklahoma and Arkansas for more than 90 consecutive days and is eligible for

enrollment in HealthChoice USA. (Required only if the employee is enrolling in the HealthChoice USA plan.)

Insurance Coordinator Signature _______________________________________ Date ____________________

Revised 08/25/2015