Fillable Office Of Group Benefits - Enrollment Change Form printable pdf download

STATE OF LOUISIANA - OFFICE OF GROUP BENEFITS - ENROLLMENT/CHANGE FORM

AGENCY NUMBER

AGENCY NAME

DATE OF HIRE

ANNUAL SALARY

EMPLOYEE NAME CHANGED TO

PURPOSE

 Waiver of Coverage

 Agency Transfer

 New Enrollment

 Reinstate Coverage

 Re-enrollment - Previous Employment

 Rehired Retiree

 Annual Enrollment

 Add/Delete Dependent(s)_________________________ Reason for Addition/Deletion_____________________________________________

Date

 Surviving Spouse/Dependent

 Special Enrollment

 Late Applicant

 Retired ______________________________

Date

 Employment Terminated ______________________________

 Deceased ______________________________

Date

 Cancel all coverage (health and life) ________________________________________

 Other _________________________________________

Reason for Cancellation

PERSONAL INFORMATION (Please print or type)

NAME (LAST, FIRST, MIDDLE INITIAL)

SOCIAL SECURITY NUMBER

DATE OF BIRTH

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

EMAIL ADDRESS

SEX

MARITAL STATUS

DATE OF MARRIAGE

DATE OF DIVORCE

(

)

 M  F

 SINGLE  MARRIED

HEALTH PLAN SELECTED (Write in health plan selection)

LEVEL OF MEDICAL COVERAGE

 No coverage

 Employee Only

 Employee + Children/Child

 Employee + Spouse

 Family

NAME

RELATIONSHIP

SEX

BIRTH DATE

ADD/

SOCIAL SECURITY NUMBER

HEALTH

DEP.

(LAST, FIRST, MIDDLE INITIAL)

(MM/DD/YYYY)

DELETE

LIFE

SPOUSE

 M

 ADD

 YES

 F

 DELETE

DEPENDENT

 M

 ADD

 YES

 F

 DELETE

DEPENDENT

 M

 ADD

 YES

 F

 DELETE

DEPENDENT

 M

 ADD

 YES

 F

 DELETE

DEPENDENT

 M

 ADD

 YES

 F

 DELETE

RETIREE 100

C.O.B.R.A.

 Employee Only

 Dependent Only  Employee + 1 Dependent

 Prior F/T Terminated  Divorced Spouse

 Dependent

MEDICARE

LIFE INSURANCE (check one only)

EMPLOYEE

SPOUSE



No Coverage



No Coverage

BASIC

BASIC PLUS SUPPLEMENTAL



Hospital (Part A)



Employee/No Dependent Coverage



Medical (Part B)



Employee/Dependent Coverage



Employee/Dependent Coverage



Drugs (Part D)

Eligible Spouse $1000 Eligible Child $500

Eligible Spouse $2000 Eligible Child $1000

A COPY OF MEDICARE CARD MUST BE ATTACHED



Employee/Dependent Coverage



Employee/Dependent Coverage

Eligible Spouse $2000 Eligible Child $1000

Eligible Spouse $4000 Eligible Child $2000

Annual Salary _____________ Date of Last Salary Increase ______________ Face Life _______________



WAIVER OF COVERAGE

I waive all coverage offered through the Office of Group Benefits. I understand that if I enroll for OGB offered life insurance at a future date, the cover-

age I receive will be subject to evidence of insurability.

NOTE TO AGENCY REPRESENTATIVE: If the employee waives his/her right to all coverage, he/she must sign an enrollment document. A copy of this

document is to be retained by the agency as evidence the employee was offered coverage within 30 days of eligibility and the employee declined. The

original of this document is to be transmitted to the Office of Group Benefits.



ACKNOWLEDGEMENT OF COVERAGE LIMITATIONS

» I understand that I must provide appropriate documents to OGB to verify eligibility of all covered dependents. I acknowledge that my application

for dependent coverage will not be approved until all required documents are received.

» I acknowledge that I have reviewed the descriptive literature about OGB health plans available to me. I apply for participation or a change in my

participation in the named health plan and agree to be bound by its terms and conditions.

» I authorize deductions from my earnings or retirement check to pay for insurance for myself and my dependents, if applicable.

» I certify that the information provided on this form is true and correct. I understand that if I provide false information on this form, it may result in

denial or recision of coverage retroactive to the initial day of coverage. A copy of my signature is as valid as the original.

» I accept that this declaration will become a part of my application for coverage.

_____________________________________________________________________________________________________________________________

Employee Signature

Date

Agency Representative Signature

Date

GB-01

REV 1-14