Contractual Health Benefits Enrollment Form - State Of Maryland
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4STATE OF MARYLAND
CONTRACTUAL / VARIABLE HOUR EMPLOYEES
HEALTH BENEFITS ENROLLMENT AND CHANGE FORM FOR JANUARY 2015-DECEMBER 2015
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: ________________________________________________
Works 30 hours per week or an
Pay Center
average of 130 hours per month:
Central Payroll
Work E-mail: ___________________________________________________
Yes
No
University
Social Security Number: __ __ __ /__ __ / __ __ __ __
Agency Code: __________
Check Dist. Code: ___________
Date of Birth: __ __ /__ __ / __ __ __ __
(if applicable)
M M / D D /
Y Y Y Y
*Please attach completed Checklist and Employee Questionaire
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Contractual/Variable Hour Employee State Subsidy Eligible
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.
Contract Period From:____________ To: ____________
Add dependent because of:
Marriage
Date: ____________
Contractual/Variable Hour Employee NO State Subsidy
Birth/Adoption/Appointed Permanent Legal Guardian
Date: ___________
Other Reason: ____________ ___________________________
Contract Period From:____________ To: ____________
Remove dependent because of:
Divorce/Limited Divorce/Legal Separation
Date: ____________
Open Enrollment - Effective January 1st
Date: ____________ (Attach copy of Death Certificate)
Death
Dependent no longer eligible
Date: ____________
Cancel all Coverage in all Plans/Reason: _________________
Reason: _______________________________________________________
____________________________________________________
Other Change: ____________________________________________________
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:
If eligible, the State subsidy applies only to medical and prescription
____ Reviewed
____ Processed
coverage. Employee pays full premium for all other coverage elected.
____ Audited
Health benefits information and forms are available on our website:
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Parent category: Medical