Combined Insurance Enrollment Form - City Of Toppenish
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4Combined Insurance Enrollment Form
Complete entire form to enroll or make changes.
Enrollment
Changes
Has there been a change that affects your insurance? Please fill in your name and SSN.
Then check all the changes that apply to you and complete the entire form.
❏ New hire
❏ Name ❏ Address ❏ Marriage ❏ Domestic Partnership ❏ Divorce ❏ Legal separation ❏ Beneficiary
❏ New group
❏ Open enrollment
❏ Other (be specific)
for medical &
❏ Add dependent (check reason) ❏ Marriage ❏ Domestic Partnership ❏ Newborn
dental only
❏ Other reason (be specific)
❏ Drop dependent (check reason) ❏ Overage dependent
❏ Other reason (be specific)
Employee
Please print legibly in blue or black ink.
SSN
Employee Name (last, first, initial)
Date of birth
Gender
❏ Single ❏ Married Date married:
❏ Divorced
Date divorced:
❏ Domestic partnership Date met DP criteria:
❏ Partnership termination Date terminated:
Home / mailing address
Home phone (with area code)
City
State
Zip
Type of coverage requested (check all that apply): ❏ Medical ❏ Dental ❏ Life ❏ Long-term disability ❏ Vision ❏ EAP
Carriers and specific plans are listed on the back of this form.
Are you covered by any other insurance now or in the past three months? ❏ Yes ❏ No
If yes, complete below.
Effective date
Termination date
Insured’s SSN
Name (last, first, initial)
Group#
Policy #
Type of insurance (medical. dental, etc.)
Name of other insurance company
Please list spouse/domestic partner who should be covered on your insurance. Leaving
Spouse/Domestic Partner
them off will terminate coverage. Proof of dependency may be requested, including, but not limited
to, marriage certificate, affidavit of marriage/domestic partnership, divorce papers.
SSN
Spouse/DP name (last, first, initial)
Date of birth
Gender
Type of insurance requested: ❏ Medical ❏ Dental ❏ Vision ❏ Life
Is spouse/domestic partner covered by any other insurance now or in the past three months? ❏ Yes ❏ No
If yes, name of other insurance company.
Type of insurance (medical, dental, etc.)
Group / Policy #
Phone #
Effective date
Termination date
Your signature is required on page 3 of this form.
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