Form Dirpef14 - Direct Pay Enrollment Form 2015 Health Benefits
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4STATE OF MARYLAND
DIRECT PAY ENROLLMENT FORM
JANUARY 2015-DECEMBER 2015 HEALTH BENEFITS
PERSONAL DATA
PLEASE PRINT CLEARLY
EMPLOYEE/FORMER EMPLOYEE/RETIREE INFORMATION
FORMER DEPENDENT INFORMATION
(if different from employee’s information)
Name: __________________________________________________
Name: __________________________________________________
LAST
FIRST
MI
LAST
FIRST
MI
Address: _____________________________ Apt/Condo: ________
Address: _____________________________ Apt/Condo: ________
City: _______________________ State: _____Zip Code: ________
City: _______________________ State: _____Zip Code: ________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Personal E-mail: _________________________________________
Personal E-mail: _________________________________________
Work E-mail: ____________________________________________
Work E-mail: ____________________________________________
Social Security Number: __ __ __ /__ __ / __ __ __ __
Social Security Number: __ __ __ /__ __ / __ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
Date of Birth: __ __/__ __/__ __ __ __
MM /DD/ YYYY
MM /DD/ YYYY
Sex:
LEGAL MARITAL STATUS:
Male
Sex:
LEGAL MARITAL STATUS:
Male
Single
Widowed
Female
Single
Widowed
Female
Married
Divorced
Married
Divorced
Limited Divorce/Legal Separation
Limited Divorce/Legal Separation
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
COBRA Date of Qualifying Event: __________
Open Enrollment - Effective January 1st
Are you on Medicare?
Yes
No
New Enrollment
Part-Time Employee (Less than 50%)
Cancel all Coverage in all Plans/Reason: _______________________
LAW-MILITARY (Long Term Leave of Absence – Military)
Change in Family Status
(See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event
Effective Date of LAW-MILITARY: __________
Add dependent because of:
End Date of LAW-MILITARY: __________
Marriage
Date: ___________
LAW – PERSONAL
Birth/Adoption/Appointed Permanent Legal Guardian
(Long Term Leave of Absence Without Pay)
Date: __________
Effective Date of LAW-PERSONAL: __________
Other/Reason: ________________________________________
End Date of LAW-PERSONAL: __________
Remove dependent because of:
(May not exceed 2 years)
Divorce/Limited Divorce/Legal Separation Date: ___________
LAW-OJI (Long Term Leave of Absence – On the Job Injury)
Date __________ (Attach copy of Death Certificate)
Death
Effective Date of LAW-OJI: __________
Dependent no longer eligible
Date: _______________
End Date of LAW-OJI: __________
Reason: _____________________________________________
(May not exceed 2 years)
Other: _______________________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED OR HAND-DELIVERED TO:
Employee Benefits Division
EBD Use Only:
Enrollment Unit
____ Reviewed
301 W. Preston Street, Room 510
____ Processed
Baltimore, Maryland 21201
____ Audited
Hours of Operations: Monday - Friday 8:30 a.m. - 4:30 p.m.
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 / Email: EBD.mail@maryland.gov
Health benefits information and forms are available on our website:
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