Fillable Office Of Group Benefits - Enrollment Change Form (Page 2 of 2) in pdf

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

(PAGE 2 of 2)

AGENCY NUMBER

AGENCY NAME

PRIMARY PLAN PARTICIPANT / EMPLOYEE NAME

SOCIAL SECURITY NUMBER

Section 4 – Life and Flexible Benefits Plan Selection

LIFE INSURANCE (check one only)

OGB FLEXIBLE BENEFITS (check all that apply)

DECLINE LIFE INSURANCE COVERAGE

BASIC

BASIC PLUS SUPPLEMENTAL

Flexible Benefits (Actives Only)



Employee/No Dependent Coverage



Decline Flexible Spending Account(s)



Employee/Dependent Coverage



My Agency Does Not Participate in OGB’s Flexible Benefits

Eligible Spouse $1000 Eligible Child $500

Eligible Spouse $2000 Eligible Child $1000

Plan



Employee/Dependent Coverage



Employee/Dependent Coverage



I Do Want to Participate and Acknowledge that I have

Eligible Spouse $2000 Eligible Child $1000

Eligible Spouse $4000 Eligible Child $2000

completed the Flexible Spending Arrangement Enrollment

Form.

Annual Salary

Date of Last Salary Increase

Face Life

Section 5 – Acknowledge Offer and Decline Health Insurance Coverage



ACKNOWLEDGE OFFER AND DECLINE HEALTH INSURANCE COVERAGE

I have been offered health coverage for me and my eligible dependents. I have voluntarily elected to decline the coverage as indicated below. If I

choose to apply for health coverage at a later date, I understand that I may only enroll for health coverage during annual enrollment or as otherwise

specified in the OGB health plan document in the event I, or my eligible dependents have a Plan Recognized Qualified Life Event.

Important: The Affordable Care Act requires each individual to have basic health insurance coverage (known as minimum essential coverage), qualify

for an exemption, or make a shared responsibility payment when filing his/her federal income tax return. Failure to enroll in an OGB plan or obtain

other minimum essential coverage may result in personal financial penalties.

Reason for Declining Health Insurance Offer:

Other Group Health Coverage

Other Individual Health Coverage

Medicare Medicaid Other, Explain: ______________________________________________

I am not enrolled in any health coverage and I do not accept this offer of health coverage.

I do not wish to disclose.

NOTE TO AGENCY REPRESENTATIVE: If the employee declines health coverage, he or she must acknowledge the offer of coverage in a method

determined by the agency participating employer. The acknowledgement must be retained by the agency participating employer as evidence the

employee was offered health coverage within 30 days of eligibility and the employee subsequently declined the offer of coverage.

Section 6 – Authorization

BY SIGNING THIS APPLICATION, I ACKNOWLEDGE AND CERTIFY THE FOLLOWING:



I, Primary Plan Participant, ,acknowledge that I have provided appropriate documents to OGB to verify eligibility of myself and any requested covered

dependents and those documents are included with this Application.

I apply for participation or a change in my participation in the named plan(s) and agree to be bound by the plan’s terms and conditions.



I acknowledge and authorize deductions from my earnings or retirement check to pay for insurance for myself and my dependents as applicable.



I acknowledge and certify that the information provided on this form is true and correct. I understand that if I provide false, misleading or incomplete



information on this form, it may result in denial or rescission of coverage retroactive to the initial day of coverage.

I accept that this Acknowledgement and Certification will become a part of my application for coverage and that a copy of my signature is as valid as



the original.

I acknowledge that any disenrollment from an OGB Plan of Benefits will result in disenrollment from both Medical and Pharmacy, including, but not



limited to Medicare Part D.

Primary Plan Participant / Employee

Date

FOR AGENCY USE ONLY:

OGB Plan-Recognized Qualified Life Event (QLE) for Application

(REFERENCE OGB 2016 QLE SPREADSHEET):

QLE CODE OR QUALIFIED LIFE EVENT DESCRIPTION

QUALIFIED EVENT DATE

ADD/DROP/REINSTATE COVERAGE

ADD

DROP

REINSTATE COVERAGE

I, Agency Representative, certify that the documentation presented is appropriate and supports the occurrence of the OGB Plan-Recognized Qualified

Life Event referenced above.

Agency Representative Signature

Date

GB-01

REV 01-16

Office Of Group Benefits - Enrollment Change Form Page 2

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