1. Information About the Employee

New Employee (Employer must complete and return New Hire Form to the Office of the Bishop with this form)

Open Enrollment

TitleFirst NameM.I.Last Name
(The Rev., Mr., Mrs., Ms. Etc.)

Residence

Street

CityStateZip

Home PhoneE-mail

MaleMarriedClergy
FemaleSingle Lay

Date Coverage

Hired (Mo/Day/Yr)Effective (Mo/Day/Yr)

Birth Soc. - -

Date (Mo/Day/Yr)Sec. No.

Mailing Address (If Different)

Street

CityStateZip

Seminarian

2. Billing Information for Medical and Dental Plans

Name of Church Organization

Street

PhoneE-mailList Bill ID

City

3. Active Medical Coverage Tier: Single Employee + Spouse Employee + Child Family

Anthem BCBS PPO 75/50
Anthem BCBS EPO 80
Anthem BCBS High Deductible Health Plan (HDHP)
Cigna OAP (Open Access Plus)
Cigna OAP-IN (Open Access Plus In-Network)
Kaiser Low (EPO 80)
Kaiser Mid Option EPO / I Waive my right to medical coverage
I would like to sign up for EAP only coverage
(This coverage is $5 per family and is available for those who waive their right to medical coverage. It is included in all Medical Trust medical plans.)

4. Active Dental Coverage Tier: Single Employee + Spouse Employee + Child Family

CIGNA Basic Dental
CIGNA Dental + Ortho / I Waive my right to dental coverage

5. Information About Your Dependents (Including Spouse)

List dependents and check coverage desired. Dependents 19 and over may be eligible – check with your administrator for guidance. If your group offers domestic partnership coverage, attach supporting documentation with this form. For more space, attach an additional Enrollment Form.

CoverageFull NameRelationship Soc. Sec. No. Birth Date (M/D/Y)Gender

Medical Male

DentalFemale

Medical Male

DentalFemale

Medical Male

DentalFemale

6. Signatures – Employee & Employer

The employee, and employer must sign this form. By signing, the Employer certifies the employee is eligible for all coverages applied for, and, to the best of the employer’ knowledge, all information provided is correct.

Employee’s Signature*Date

*Include Power of Attorney documentation if applicable

Name of Church or Organization

Employer’s SignatureDate

7. Enrollment Guidelines

  • For Group Medical Benefits, if the Health Insurance Portability and Accountability Act of 1996 (HIPAA) applies, you must include evidence of your prior health coverage with this form.
  • New employees must enroll and sign this form within 30 days of hire or eligibility date for Group Medical/Dental Insurance and send this form to the Office of the Bishop at 350 University Ave. Ste. 280, Sacramento, CA 95825.
  • If enrolling in a Managed Care Plan, attach Managed Care application. Managed Care plans do not accept late enrollments.
  • All late enrollments subject to approval.