Change Request Form
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1
2CHANGE REQUEST FORM
Please either mail this form to SIHO, 417 Washington Street, Columbus, IN 47201
attn: Membership, fax it to 812-373-8717 or email to .
Employer ______________________________________________________ Group No. ________________________________
Employee ______________________________ ID # __________________________ Phone (______)_____________________
Name _______________________________________ Hgt/Wgt __________________ Date of Birth ______________________
Please check which coverage(s) to add:
Medical
Dental
Vision
Dependent Life
Reason to add _______________________ Spouse employed: Yes No Spouse’s S.S. #_________________________
What is the Qualifying Event:
Date of Qualifying Event___________
__________
If enrollment is due to a qualifying event, proof of qualifying event (divorce decree, Certificate of Creditable Coverage, Medicaid or other) must accompany this form.
Employer Name/Address___________________________________________________________________________________
Spouse insured elsewhere? Yes
No
If yes, Insured by _______________________ Policy #: ___________________
Full Name
Sex
Birthday
S.S. Number
Full Time
Reason to Add
Date of Qualifying
Student
M / F
M/D/Y
Event
(Y/N)
Please check which coverage(s) to add:
Medical
Dental
Vision
Dependent Life
Children insured elsewhere? Yes No If yes, Insurance Co.: _______________________ Policy #: __________________
Are any of the other Dependents listed above in the legal custody of another person? Yes
No
If yes:
If enrollment is due to a qualifying event, proof of qualifying event (divorce decree, Certificate of Creditable Coverage, Medicaid or other) must accompany this form.
Dependent
Person with Legal Custody
Relationship to Dependent
Address of Custodian
Employee Termination, indicate last day of work ___________________________________
Voluntary
Involuntary
(Benefits will end on last day of month following termination.)
Employee Request for Termination of Benefits (benefits will end on last day of month):
Delete employee coverage, effective date _______________
Reason: _______________________
Please check which coverage(s) to delete:
Medical
Dental
Vision
Dependent Life
Life
Delete spouse’s coverage, effective date ________________
Reason: _______________________
Please check which coverage(s) to delete:
Medical
Dental
Vision
Delete children’s coverage, effective date ________________
Reason: _______________________
Please check which coverage(s) to delete:
Medical
Dental
Vision
Change Name:
Employee Name
Dependent’s Name _________________________________________________
Reason:
Marriage
Divorce
Other, describe _________________________________________
Change Name to _____________________________________________________________________________________________
Change address:_________________________________________________________________________________________
New Address: ___________________________________________________________________________________________
Change Life Insurance Beneficiary:
Primary - Full Name:_____________________________________________ Relationship_____________________________ %___________
Secondary - Full Name:___________________________________________Relationship_____________________________ %___________
I authorized SIHO to make the above changes to my current benefits.
Note: No employee signature is necessary if employment is terminated. All other changes must be authorized by the employee.
Employee signature: ___________________________ Date: ___________________ Employer signature: _____________________________
WARNING: any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits and application or files a claim containing
false or deceptive statements is guilty of insurance or health care fraud under state and/or federal law.
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