2015 Kehp Active Employee Health Insurance Add-Drop Form
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1
2
3
4Do No
ot Staple
Kentuc
cky Employees’ H
Health Plan
Depart
tment of Employe
e Insurance
KEHP.K
Y.GOV ● 1‐888‐581‐
‐8834
20
015 KEHP
ACT
IVE EMPLO
OYEE HEALT
TH INSURAN
NCE ADD/D
DROP FORM
M
Sectio
on 1: To Be Comp
pleted by Insura
ance Coordinato
or/HR Generalis
t
Emplo
oyee’s SSN
/ /
Emplo
oyee Personne
l Number
Hom
e County
Code
e
Comp
pany Name
Company
Number
/ /
Coverage
Effective Date
/ /
/
Org. U
Unit Number
Date
of Hire
Reaso
on for submiss
ion:
Qu
ualifying Event
Other
Sectio
on 2: Demograp
phic Information
n
/ /
Na
ame (Last, First,
MI)
Date of Birth
Street Address
s
Ho
ome Phone Num
mber
Ce
ell Phone Numb
er
H
ome Email Addr
ress
W
Work Email Addre
ess
City, State, ZIP
Gend
der Male
F
Female
Within
n the past 6 month
hs, have you, or a s
spouse or depend
ent(s) age 18 and
over, to be covere
ed under your insu
urance plan,
Yes
N
No
used to
obacco regularly?
Yes
No
Marrie
ed
Sectio
on 3: Change Inf
formation
Pleas
e select one Q
QE Reason
Date of E
Event:
/
/ /
Adding De
pendents
D
ropping Depen
ndents
M
Marriage
Copy of m
arriage certifica
ate attached?
Divo
orce
Copy of D
Divorce Decree a
attached?
Yes
No
Yes
No
B
Birth/Adoption o
of Child
Copy of birth c
certificate or
place
ement documen
nts attached?
Dea
ath No d
documentation r
required.
Yes
No
L
Loss of Other Cov
verage Let
tter from HR or C
Certificate of
Gain
ning Other Cove
erage Letter
from HR or Cert
tificate of
Prior Coverag
ge attached?
P
Prior Coverage a
attached?
Yes
No
Yes
No
L
Loss of KCHIP/Me
edicaid
MET for
rm attached?
Gain
ning Medicare/M
Medicaid
MET form at
ttached?
Yes
No
Yes
No
G
Guardianship/Co
ourt Order Co
py of Court Ord
er attached?
Oth
her Permitted (ex
xplain):
Yes
No
Sectio
on 4: Plan Electio
on
Benefit O
Option
Coverage Le
evel
L
LivingWell CDHP
I agree t
to the LivingWe
ll
Sing
le (self only)
p
promise
L
LivingWell PPO
I agree
to the LivingWe
ell
Pare
ent Plus (self and
d child(ren))
p
promise
S
Standard PPO
Coup
ple (self and spo
ouse)
S
Standard CDHP
Fam
ily (self, spouse,
, and child(ren))
Waive
e Health Insura
ance and
Waiver H
HRA
Waiver Dent
tal/Vision ONL
LY HRA
NO HRA –
– not eligible
Elect:
:
Last
Updated 03/
/2015
Page 1
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