Buffalo City School District Employee Health Insurance Enrollment Form Page 10
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15BUFFALO CITY SCHOOL DISTRICT
RETURN FORM TO:
Buffalo City School District
EMPLOYEE HEALTH INSURANCE ENROLLMENT FORM
Benefits Department Room 806 City Hall
Buffalo, New York 14202
Telephone: 816-3754
NEW ENROLLMENT
CHECK ONE:
Plan A – BC/BS TRADITIONAL (Indemnity Plan)
Plan B – Plan of Benefits formerly offered through INDEPENDENT HEALTH (POS)
Plan C – Plan of Benefits formerly offered through UNIVERA (POS)
Plan D – COMM. BLUE or
COMM. BLUE Plus -
(CIRCLE co-pay choice: $5/10 or $0/15 (PCP/Specialist)
Applicant’s Last Name
First Name
MI
Home Telephone
Alternate Telephone
Social Security Number
Street Address
City
State
Zip Code
Date of Birth
Primary Care Physician – Required (except with Plan A)
Email Address
Male
Female
Marital Status:
Single
Married Date:
/
/
Divorced Date:
/
/
Widowed Date:
/
/
Date of Birth
Primary Care Physician – Required
Names of Eligible Dependents to be Covered
Social Security #
Relationship
Email address
MM/DD/YY
for each member (except with Plan A)
Spouse’s Name
Husband
Wife
Dependent
Son
Daughter
Dependent
Son
Daughter
Dependent
Son
Daughter
Dependent
Son
Daughter
Is your spouse employed by or retired from the Buffalo City School District?
Yes
No
Does any individual listed above have additional health coverage, including, but not limited to Medicare?
Yes
No (Attach a copy of the card.)
EMPLOYER SECTION – DO NOT COMPLETE
IMPORTANT – PLEASE READ AND SIGN BELOW
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for
Group #:
Sub Group:
Class:
the purpose of misleading information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars
Eligibility Date:
Medicare A Date:
and the stated value of the claim for each such violation.
I authorize any licensed doctor, hospital or other health care provider to provide my plan with any
Retirement Date:
Medicare B Date:
information requested concerning medical services I or members of my family have received, which the
plan determines is necessary for the operation and regulation of the plan.
This information will be kept confidential.
Coverage:
Single
Family
Union:
Status:
______________________________________________________________
_____________________
Group Administrator:
Date:
Applicant’s Signature
Date
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