2024 Archdiocese of Atlanta / Lay Employee Quick Guide - Flipbook - Page 51
EMPLOYEE ENROLLMENT/CHANGE FORM
APPLICATION BEING MADE FOR: HEALTH PLAN
Plan Option Selection:
(Check One):
For completion by employer:
Application being made for:
Value Plan
Premier Plan
EMPLOYEE COVERAGE
EMPLOYEE + SPOUSE COVERAGE
EMPLOYEE + CHILD(REN) COVERAGE
EMPLOYEE + FAMILY COVERAGE
DATE OF BIRTH WSH
EMPLOYEE NAME - LAST, FIRST, MIDDLE INITIAL
New employee coverage
Special enrollee (attach proof)
Late enrollee/open enrollment
SEX MALE
SOCIAL SECURITY NO.
FEMALE
HOME ADDRESS
CITY
STATE
ZIP CODE
AREA CODE
PHONE NUMBER
SPOUSE ADDRESS (if different)
CITY
STATE
ZIP CODE
AREA CODE
PHONE NUMBER
MARITAL STATUS
Single
Married
Separated
Widowed
DIVISION (
Divorced
Date:
One)
01 - PRIESTS
02 - LAY
03 – SEMINARIANS
LOCATION NAME
EMPLOYER:
04 - RELIGIOUS
EMAIL ADDRESS (optional)
5RPDQ&DWKROLF$UFKGLRFHVHRI$WODQWD
,IRXDUHDGGLQJDGHSHQGHQWRXPDQHHGWRSURYLGHDGGLWLRQDOGRFXPHQWDWLRQWRSURYHWKHLUHOLJLELOLW
PRINT NAMES OF DEPENDENTS APPLYING FOR
COVERAGE: (LAST, FIRST)
(LIST THE NAME OF EVERY DEPENDENT THAT WILL BE COVERED)
SOCIAL SECURITY
NUMBER
LEGAL RELATIONSHIP: SPOUSE, CHILD,
STEP-CHILD, ETC
GENDER:
(M / F)
DATE OF BIRTH
MO DAY YR
I hereby authorize any health plan, provider of health care services or their Business Associates who have any records, knowledge, or Protected Health Information of me or any family
member for whom coverage is requested, to share the information with Corporate BeneÞt Services of America, Inc., and its Business Associates who provide services for the health plan
described herein, for the purposes of determining eligibility for enrollment or underwriting for me and for my family members for the health plan. A photographic copy of this authorization
shall be as valid as the original.
I hereby request the amount(s) and BeneÞts for which I am or may become eligible and hereby authorize my employer to deduct the required contributions, if any, from my earnings.
I certify that the information I have set forth in this application is true and correct to the best of my knowledge. No information has been knowingly withheld or omitted concerning me or my
dependents. I understand that providing false information in this application is a crime and may result in the denial of claims or cancellation of coverage. In addition I may be subject to civil
and/or criminal penalties.
X
Sign your name, DO NOT PRINT OR TYPE
Date
Providing the above authorization makes it possible to determine your eligibility for enrollment in this health plan. As described in the Notice of Privacy Practices, you may revoke this
authorization at any time as provided by applicable law and except to the extent that this authorization has been relied upon.
FOR EMPLOYER USE ONLY/EMPLOYEE BENEFITS OFFICE
DIVISION # ____________
LOCATION # ____________
DATE OF FULL TIME EMPLOYMENT ________________
EFFECTIVE DATE OF CHANGE / COVERAGE _______________
ORIGINAL PART TIME HIRE DATE
WHAT IS THE MINIMUM NUMBER OF HOURS WORKED PER WEEK?
___________________________
_________________
Comments: ___________________________________________________________________________________
FOR MERITAIN HEALTH USE ONLY
Timely
Late
Special
New
Prior Plan Credits
Wait Start
Group Number
Cert Start _______________________________
Effective Date
Cert End
Account Rep
10974
LF _____ MD ______ DI _____ DN______DL________OTH ______VS ______24 _______SAL ________LTD _______PPO _________
DEPT ______ LIFE2 ________ CV SUFFIX ______________COMMENTS:_______________________________ RETURN TO REP: ________________
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