Get Employee Eligibility Statement - Trustmark Companies

The Employee Eligibility Statement is an essential form for all full-time employees of Trustmark Companies. Completing this form accurately ensures that eligible employees and their dependents receive appropriate benefits and coverage under their employer's health plan.

Follow the steps to fill out the Employee Eligibility Statement with ease.

1. Press ‘Get Form’ button to access the Employee Eligibility Statement and open it for editing.
2. Begin with the employer information section. Fill out the company name, location including state and ZIP, plan choice if applicable, group number, physician/hospital network, and proposed effective date.
3. Next, complete the employee information section. Provide your first name, middle initial, last name, address, city, state, ZIP code, sex, date employed full time, social security number, birth date, work phone, home phone, email address, job title, marital status, hours worked per week, and annual salary.
4. If you are applying for life insurance or accidental death and dismemberment coverage, fill out the beneficiary information with the name, relationship, and other relevant details.
5. In the coverage information section, indicate whether you are applying for coverage or waiving it. If waiving, ensure to check the appropriate boxes for yourself and any dependents.
6. Choose the coverage you are applying for, checking only one option from employee only, employee with spouse or partner, employee with children, or all.
7. Indicate the reason for enrollment, selecting from options such as new group plan, new hire, plan change, late enrollment, or special enrollee.
8. Complete the dependent information section by listing dependents that are to be covered, including their birth dates and social security numbers.
9. Address any prior or current coverage in the prior/other coverage section. Note if you or any dependents had prior major medical coverage and fill out the requested details.
10. The medical information section requires answering questions about tobacco use, previous medical conditions, and weight and height for you and your dependents.
11. Provide details for any positive health indicators related to HIV, hospitalizations, and past medical interventions.
12. Complete the agreement and authorization section which includes affirming the accuracy of your provided information and understanding the privacy practices.
13. Finally, review all completed information. You can save your changes, download, print, or share the form as needed.

Complete your Employee Eligibility Statement online today for timely processing of your benefits.