Fillable Request For Group Coverage/enrollment Form printable pdf download

Request For Group Coverage/enrollment Form

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Employee Benefit Trust

1205 Windham Parkway

Romeoville, IL 60446

800.807.9460 / 630.378.3005 fax

Request for Group Coverage/Enrollment Form

Due to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), certain provisions contained

within this plan may or may not apply while you are covered. PLEASE READ THE FOLLOWING CAREFULLY.

SPECIAL ENROLLMENT RIGHTS

If you waive (or decline) enrollment for yourself or your dependents because of other health coverage, you may

later enroll within 31 days of a loss of other health coverage. Loss of health coverage includes separation,

divorce, death, termination of employment, reduction in work hours, exhaustion of COBRA continuation or

state continuation, or if employer contributions toward your coverage have terminated.

In addition, any change in your family status may allow you to enroll within 31 days of the event. It includes

marriage, birth, adoption, or placement for adoption of a child. (See Special Enrollment Form)

With the Onset of the Children’s Health Insurance Program Reauthorization Act of 2009 two additional

enrollment opportunities apply for CBEBT Trust members and their enrolled dependents if either of the

following occurs:



Termination of Medicaid or Children’s Health Insurance Program (CHIP) due to loss of eligibility; or



Become eligible for state premium assistance under Medicaid or CHIP.

Trust members and their dependents who are eligible but not enrolled for coverage under the Christian

Brothers Employee Benefit Trust are allowed up to 60 days to request coverage under the group health plan.

Please contact your employer for any clarification regarding your enrollment in the CBEBT.

Rev.9/23/2014

Request For Group Coverage/enrollment Form

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