Get Benefitmall Employee Election Form 2014-2025

EMPLOYEE ELECTION FORM New Hire Re-Hire BMLL Billing Effective Date Team THIS IS NOT AN APPLICATION FOR INSURANCE Carrier Group See Coverage Boxes COBRA/Continuation Group Administered Add Coverage Employer with 20 or more employees Last Name First Name M. I. Yes Employer Street Address Social Security Number City State Zip Gender Male Female Date of Marriage Home Telephone Business Telephone Marital Status S M D W Are you actively working for the employer listed above as defined in your insurance contract No Full-time Part-time Occupation Employee Class MEDICAL PLAN if offered 1 Carrier Plan Type Carrier Group Employee Only DENTAL PLAN if offered Date of Birth Date Full-Time Employment Hours Worked/Week Annual Salary VISION PLAN if offered LIFE AND AD D if offered Waive Coverage VOL LIFE SPOUSE Employee Spouse Employee / Child ren Family DEP. CHILD Over 65 Retired Working Medicare or Complimentary to Medicare CareFirst-Individual only and benefit coverage only. Not eligible for HSA Provider Name Family Dentist Office LTD if offered VOL* LTD Last Full First Plan Benefit / Wk. Life Insurance Beneficiary if coverage offered Relationship Number Birth Date Sex Student Y/N Disabled For HMO and POS Plans Primary Care OBGyn Carrier Assigned Provider and name Existing Patient Emp Sp Chd OTHER HEALTH INSURANCE Please note You must complete this section if waiving or enrolling in medical coverage and your company offers Dual Coverage OR if you are currently covered under Medicare. Do you or your dependents have health coverage with another insurer No Yes If Yes Effective Date Other Carrier name/policy Will this coverage be continued No If No Term* Date Are you covered by Medicare No Yes Effective Date Part A // Effective Date Part B // Medicare Is your spouse or dependent s covered by Medicare No Yes Effective Date Part A // Effective Date Part B // Name of spouse or dependent s covered if applicable Medicare Spousal Coverage Individual Coverage Military Coverage COBRA Medicare as primary under TEFRA No Coverage CERTIFICATION I hereby certify that I am the spouse parent or legal guardian of the dependent s shown above. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison* Voluntary benefits may be subject to pre-existing condition exclusions please refer to your policy for more information. I authorize my employer to make any necessary payroll deductions and also declare that any disability coverage in force and applied for with respect to myself is less than 75 of my current monthly earnings 60 for intermediate disability income. EMPLOYEE SIGNATURE DATE If enrolling in HMO coverage please refer to the Waiver of Insurance Coverage included with this form* By checking Waive Coverage you confirm that you waive coverage and have read and understand the Waiver of Insurance Coverage information included* Dependent s dentist if different than above.