Fillable State Of Hawaii Premium Conversion Plan - College Of Social Sciences printable pdf download

PERSONNEL OFFICE USE

Employer Receipt Date

_ _ / _ _ / _ _

PCP Effective Date

_ _ / _ _ / _ _

State of Hawaii Premium Conversion Plan

DPO Signature:

Election Change Form

This form must be received by your employing department within 90 days of a qualifying event.

Changes/cancellations must be consistent with the event indicated and shall become effective on a prospective basis from the employer’s

receipt date. NOTE: Changes/cancellations for DOMESTIC PARTNERS can only be made during the annual Open Enrollment Period.

1. Name (Last, First, Middle)

2. Social Security Number (last 4-digits)

3. BU Code

xxx-xx-_ _ _ _

4. Department

5. Division or School

6. Business Phone

7. Date of Qualifying Event

_ _ / _ _/ _ _

PART A: Please check the benefits plan affected:

Medical/Prescription Drug/Chiropractic

Drug Only Plan

Vision Plan

Dental Plan

PART B: Action requested: Select box 1, 2, or 3 and the corresponding change in personal status.

1. I elect to TERMINATE my participation in the Premium Conversion Plan due to:

Open Enrollment

I will be covered as a dependent under my spouse’s new

employer’s plan or retiree health benefits plan.

My transfer to a non-eligible employment classification

My spouse, who is also a State employee, changed his/her

My loss of eligibility for coverage under a component plan

health plan enrollment to family coverage due to the

I will be covered under my new second employer’s health

birth/adoption of our child

benefits plan or a new health benefits plan offered by my

I will be placed on a leave without pay status

second employer

Other (I have attached a written explanation)

My marriage. I will be covered under my spouse’s

employer’s plan

2. I elect to CHANGE the amount of the PCP reduction of my pay from:

Self-Only to 2-party or Family enrollment; or

2-party to Family enrollment because of:

Open Enrollment

My dependent’s loss of eligibility for coverage under a health

benefits plan

My Marriage

My spouse’s health benefits plan is significantly changed or

Birth or adoption of my child(ren)

terminated

My eligible dependent (re-)joined my household

Other _____________________________________

Family to 2-party or Self-Only enrollment; or

2-party to Self-Only because of:

Open Enrollment

My spouse/dependent child becoming eligible for and

electing coverage under another health benefits plan

My Divorce/annulment of my marriage

Other _____________________________________

Death of my dependent(s)

My last dependent child becoming ineligible for

coverage

Change of health benefits plan insurance carrier because my new residence is out of the service area of my present carrier.

Change to a new employment classification where other component plans have become available or where my carrier’s plan is not

available.

3. I elect to PARTICIPATE in the Premium Conversion Plan,

Self-Only

2-party

Family enrollment

My being out of State during the entire Open Enrollment Period

My return from a leave without pay status

My loss of health benefits plan coverage because of the involuntary termination of my enrollment or my spouse’s enrollment due to:

Death

Divorce/Annulment of my marriage

Eligibility/employment termination

PART C:

I understand that I am making an election that is binding for the remainder of the plan year. I also understand that during

this period I may not modify my reduction in pay unless (1) the plan is terminated, (2) there is an increase in the amount of

required employee contributions for the coverage which I have elected in conjunction with this current Election Change Form, or

(3) there is a change in my personal status that qualifies under the Internal Revenue Code.

Employee Signature:

Date:

PCP-2 Rev. 3/08

State Of Hawaii Premium Conversion Plan - College Of Social Sciences

Related Articles

Related forms

Related Categories