Employee/Subscriber Information Social Security Number BCN Group and Division # Date of Hire Employee Department Employee Group Employee ID - - 00124677 - / / Effective Date Last Name First name MI Date of Birth Home Phone / / / / ( ) - Home Address City State Zip Code Gender Marital Status Work Phone M F S M ( ) - Plan: Healthy Blue Living HMO Desired Action Enroll or Cancel – Reason for Enrollment Reason for Cancellation Waive upon hire New Hire/Rehire Surviving Spouse No Longer Employed Loss of Dep Status Terminate coverage Birth/Adoption/Foster Care Return to Work (LOA) Deceased Other Insurance DEI Event Other Reason: Divorce Open Enrollment Single (employee only) Marriage LOA Double Open Enrollment Cobra Enrollment Other Reason: (employee & 1 family member) Transfer Family (employee & 2 or more family members) New Suffix: List all dependents to be Last Name First Name MI Gender Date of Birth Social Security enrolled/cancelled M Spouse Add DEI Adult Remove F / / - - M Child Age 19 - 26 Add DEI Child Y N Remove F / / - - M Child Age 19 - 26 Add F / / - - DEI Child Y N Remove M Child Age 19 - 26 Add DEI Child Y N Remove F / / - - If the permanent address of the spouse or child is different from the Employee, Please complete the information below Spouse/Child Full Name Street Address City State Zip – Child Full Name Street Address City State Zip – Do you, your spouse or children maintain other health coverage? Yes No If yes, complete below Medicare Coverage Full Name of Insured Coverage Type Insurance Company Part A Effective Part B Effective Claim Number M D V / / / / M D V / / / / HRA Deduction Begin Date to BCBSM I have read and understand the conditions, eligibility, & required documentation on Page 3 HR USE ONLY Employee Signature Date / / / /
Employee/Subscriber Information Social Security Number - - BCN Group and Division # 00124677 - Date of Hire / / Employee Department Employee Group Employee ID Effective Date / / Last Name First name MI Date of Birth / / Home Phone ( ) - Home Address City State Zip Code Gender M F Marital Status S M Work Phone ( ) - Plan: Healthy Blue Living HMO Desired Action – Enroll or Cancel Waive upon hire Terminate coverage Single (employee only) Double (employee & 1 family member) Family (employee & 2 or more family members) Reason for Enrollment Reason for Cancellation New Hire/Rehire Birth/Adoption/Foster Care DEI Event Marriage Open Enrollment Surviving Spouse Return to Work (LOA) Other Reason: No Longer Employed Deceased Divorce LOA Loss of Dep Status Other Insurance Open Enrollment Cobra Enrollment Transfer New Suffix: Other Reason: List all dependents to be enrolled/cancelled Last Name First Name MI Gender Date of Birth Social Security Spouse DEI Adult Add Remove M F / / - - Child Age 19 - 26 DEI Child Y N Add Remove M F / / - - Child Age 19 - 26 DEI Child Y N Add Remove M F / / - - Child Age 19 - 26 DEI Child Y N Add Remove M F / / - - If the permanent address of the spouse or child is different from the Employee, Please complete the information below Spouse/Child – Full Name Street Address City State Zip Child – Full Name Street Address City State Zip Do you, your spouse or children maintain other health coverage? Yes No If yes, complete below Full Name of Insured Coverage Type Insurance Company Medicare Coverage Part A Effective Part B Effective Claim Number M D V / / / / M D V / / / / I have read and understand the conditions, eligibility, & required documentation on Page 3 HR USE ONLY HRA Deduction Begin Date to BCBSM / / Employee Signature Date / /
hr-benefits-hmo-restricted-fillable-rev-110218.docx