Form Lg07 - Enrollment Form - 2017
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4Form LG07
FOR LGHIB USE ONLY
Revised 9/16
LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM
Date: _____________
2017 ENROLLMENT FORM
Initials: ___________
SOUTHLAND NATIONAL VOLUNTARY INSURANCE
SUBSCRIBER INFORMATION (Please print or type.)
CHECK PLAN ELECTED
Name (First, Middle Initial, Last)
Sex
Vision
Social Security Number
Date of Birth
(Monthly premium $20)
Mailing Address
Dental
(Monthly premium $40)
City
State
ZIP Code
Vision and Dental
(Monthly premium $60)
Home Telephone Number
Work Telephone Number
A minimum enrollment of 12
(
)
(
)
Ext:
months required for
employees/ dependents
E-mail Address:
without qualifying status
change.
Employment Status (Check One)
P
Full-time Employee
ACA Eligible
Elected Official
Retired (Not Medicare Participant)
Retired (Medicare
articipant)
(Must submit documentation)
NOTE: BY LISTING FAMILY MEMBERS BELOW YOU ARE APPLYING FOR AND REQUESTING FAMILY COVERAGE.
Documentation is required.
See back of form.
First Name
Initial
Last Name
Relationship to Employee
Date of Birth
Social Security Number
Male Spouse
Female Spouse
Son
Daughter
Stepson
Stepdaughter
Son
Daughter
Stepson
Stepdaughter
Son
Daughter
Stepson
Stepdaughter
Son
Daughter
Stepson
Stepdaughter
Grandson
Granddaughter
Nephew
Niece
Grandson
Granddaughter
Nephew
Niece
TO BE COMPLETED BY EMPLOYER
AFFIRMATION AND RELEASE
I hereby affirm that I have completely read and fully understand
Effective Date: ____________________________
the terms and conditions of this form. I attest that all the
representations made by me on this form are true and correct. I
understand that any misrepresentation may result in the
____________________________________
forfeiture of insurance coverage and that I will be personally
Local Government Unit Name
liable for all claims related to such misrepresentation. I further
understand that there is mandatory utilization review and I do
____________________________________
hereby give permission to release any information necessary to
evaluate, administer, and process claims for benefits to any
Account Number
person, entity or representative acting on the LGHIB’s behalf.
____________________________________
______________________________________________________
Signature of Insurance Clerk
Date
Employee Signature
Date
* A “qualifying event” is birth, marriage, adoption, death, divorce, or otherwise losing dependent status.
Dependent documentation is required before dependents can be added to coverage.
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