Form Asef15 - Active & Satellite Employeeshealth Benefits Enrollment And Change Form - 2016
Download a blank fillable Form Asef15 - Active & Satellite Employeeshealth Benefits Enrollment And Change Form - 2016 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Asef15 - Active & Satellite Employeeshealth Benefits Enrollment And Change Form - 2016 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4STATE OF MARYLAND
ACTIVE & SATELLITE EMPLOYEES
HEALTH BENEFITS ENROLLMENT AND CHANGE FORM FOR JANUARY 2016-DECEMBER 2016
PERSONAL DATA
PLEASE PRINT CLEARLY
Name: ____________________________________________________________________________________________________________
LAST
FIRST
MI
Address: _______________________________________________________________________________Apt/Condo: ________________
City: _______________________________________________ State: _______________________ Zip Code: _______________________
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
Sex:
Legal Marital Status:
Male
Single
Limited Divorce/
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Female
Married
Legally Separated
Widowed
Divorced
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
TO BE COMPLETED BY AGENCY BENEFITS COORDINATOR
Personal E-mail: ________________________________________________
Work full-time or 50% or
Pay Center
more of the normal week:
Central Payroll
Work E-mail: ___________________________________________________
University
_____________________
Work______hrs. per week
Satellite:
Social Security Number: __ __ __ /__ __ / __ __ __ __
Agency Code: __________
Check Dist. Code: ___________
Date of Birth: __ __ /__ __ / __ __ __ __
(if applicable)
M M / D D /
Y Y Y Y
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
New Employee Entry on Duty Date: ____________
Change in Family Status (See Benefits Guide for documentation requirements)
Note: Request must be made within 60 days of the date of the qualifying event.
Return from leave of absence/LAW Date: ____________
Add dependent because of:
Marriage
Date: ____________
Open Enrollment - Effective January 1st
Birth/Adoption/Appointed Permanent Legal Guardian
Date: ___________
Employee ineligible (e.g., change to part-time less than 50%)
Other Reason: ____________ ___________________________
Cancel all Coverage in all Plans/Reason:
Remove dependent because of:
____________________________________________________
Divorce/Limited Divorce/Legal Separation
Date: ____________
Death
Date: ____________ (Attach copy of Death Certificate)
Dependent no longer eligible
Date: ____________
Reason: _______________________________________________________
Other Change: ____________________________________________________
DECLINE ALL COVERAGE
By signing below, I certify that I have been given an opportunity to enroll in coverage for myself and my eligible dependents, if any. I am declining
enrollment. I FURTHER CERTIFY THAT I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health
insurance or group health plan coverage. I UNDERSTAND THAT I may be able to enroll myself and my eligible dependents in this plan if I lose, or my
eligible dependents lose, eligibility for THE OTHER HEALTH INSURANCE OR GROUP HEALTH PLAN coverage, or if the employer stops contributing
towards my or my eligible dependents’ other coverage.
X _______________________________________________
_____/______/_______
X ______________________________________________
_____/______/_______
Employee Signature
Date
Agency Benefits Coordinator Signature
Date
COMPLETED AND SIGNED ENROLLMENT FORMS MUST BE GIVEN TO YOUR AGENCY BENEFITS COORDINATOR
If you are enrolling dependents outside of Open Enrollment,
all required dependent documentation must be attached.
EBD Use Only:
Health benefits information and forms are available on our website:
____ Reviewed
____ Processed
____ Audited
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Asef14 - Active & Satellite Employees Health Benefits Enrollment And Change Form For 2015
Business
Form Cef15 - Contractual / Variable Hour Employees Health Benefits Enrollment And Change Form For January - December 2016
Legal
Related Categories
Parent category: Legal