(Please fill out this form completely.
All information is necessary for proper enrollment.) / (HR Use Only): EMPLOYMENT DATE: ___/___/___ OR
DATE CHANGED FROM PART-TIME TO FULL-TIME: ___/___/___
[Does the regular waiting period apply? Refer to Plan Document. ___ yes or ___ no]
EFFECTIVE DATE: ___/___/___
GROUP NAME:
Employer and Laborers Locals 100 & 397 / GROUP NUMBER:
090110ELL / LOCATION CODE (HR Use Only): / SEX: ___ M ___ F / DATE OF BIRTH:
___/___/___
EMPLOYEE LAST NAME: (Mark this box for name change. □) / FIRST NAME: / M.I. / SOCIAL SECURITY NUMBER:
STREET ADDRESS: (Mark this box for address correction. □) / CITY/STATE/ZIP: / HOME PHONE NUMBER:
( ) -
ENROLLMENT TYPE:
___ FIRST TIME ELIGIBLE AFTER WAITING PERIOD
___ OPEN ENROLLMENT
___ SPECIAL ENROLLMENT (Please note the date below): / TERMINATION EVENT (Please note date below):
Divorce / / , Loss of Employment / / ,
Child no longer Full-Time Student / / ,
Other: ______/ / . / MARITAL STATUS:
____ SINGLE
____ DIVORCED
____ WIDOWED
____ MARRIED (Date of current marriage / / )
SPECIAL ENROLLMENT EVENT:
Marriage / / , Birth / / , Placement for Adoption of Legal Guardianship / / , Adoption / / ,
Loss of Other Coverage / / Active to Retiree Coverage / / , Active Spouse to Spouse Retiree Coverage / / , COBRA to Active Coverage / /, Active to Disabled Coverage / /. Notes regarding special enrollment: ______
1) COVERAGES ELECTED
(Medical, RX, Dental, Vision) / __ Employee Only / __ Employee & Spouse __ Employee & Child(ren) __ Employee & Family
NOTE: You must complete the Other Health Insurance (OHI) section of this form to disclose OHI coverage either as an employee or dependent of another health plan (employer group plan, Medicare, Medicaid). Claims processing will be delayed if this information is not on file.
Complete for only for the newly eligible dependents being added to the plan.
Last Name, First M.I. / Relation Code (See below)* / Male or Female / Date of Birth / Social Security Number / Disabled?
(Need letter from Physician.) / Eligible for Other Insurance (i.e., through dependent’s employer or dependent’s spouse’s employer)?
Spouse: / SP / ___/___/___
Does your Spouse also work for Employers and Laborers Locals 100 & 397? __ YES __ NO.
Does your Spouse’s employer offer group health coverage? __ YES __ NO. If yes, type of coverage: ___Medical, ____Dental, ____ RX.
If your Spouse declines that coverage, he/she will be required to satisfy an additional $500 deductible under this Plan.
Dependent Child #1: / ___/___/___
Dependent Child #2: / ___/___/___
Dependent Child #3: / ___/___/___
Dependent Child #4: / ___/___/___
Attach additional forms if necessary.
* Relationship = child (CH), step-child (SC), adopted child (AD), under employee's legal guardianship (LG), and foster (FC). Grandchildren are only eligible if the Employee is the Legal Guardian. Refer to the Plan Document for criteria and documentation required.
2) EMPLOYEE LIFE BENEFIT: This is a Company-Paid benefit. All proceeds will go in equal shares to the primary beneficiary(s), unless different percentages are indicated below. If the primary beneficiary(s) is not living, all proceeds will go in equal shares to the secondary beneficiary(s), unless different percentages are indicated below:
PRIMARY BENEFICIARY:
1. / RELATIONSHIP TO EMPLOYEE: / PERCENTAGE: / SOC. SEC. NO.: / ADDRESS:
2.
SECONDARY BENEFICIARY:
1. / RELATIONSHIP TO EMPLOYEE: / PERCENTAGE: / SOC. SEC. NO.: / ADDRESS:
2.
______NO, I DO NOT WISH TO ENROLL in the Employee Benefit Plan although it has currently been made available. I understand that if I and/or my dependents request coverage at a later time, I/we may not be eligible. Refer to the plan document(s) for eligibility/enrollment criteria.
Signature: Date signed:
______YES, I DO WISH TO ENROLL in the Employee Benefit Plan(s) OR MAKE CHANGES as indicated above. I authorize the preceding enrollment application or change(s) of enrollment for myself and any eligible members of my family listed above. I also authorize my employer to deduct from my earnings the amount required to cover my share of payment for this Plan(s). This Plan has a Coordination of Benefits provision which I understand will be adhered to before any benefits are payable. I understand I am required to notify my employer of any situations that may affect coverage status. This includes a newborn child. I further authorize anyone providing services to me or my dependents to release to this Plan(s) any information or medical records relating to those services. I certify that all information contained in this form is true and complete to the best of my knowledge.
Signature: Date signed:
Please mail or fax completed forms to: Ekon Benefits, 4940 Washington Blvd, St. Louis, MO 63108. Fax: (314) 367-7982.
(Continued on page 2- OHI Form- Employee/Spouse)
Page 2 (OHI Form- Employee/Spouse)
OTHER HEALTH INSURANCE (OHI) INFORMATION FORM
Other Health Insurance (OHI) coverage is medical coverage through an employer-sponsored group plan and/or Medicare or Medicaid under which the member is covered either as an employee, retiree or dependent. Please fully complete the information below to identify whether or not you or any family member covered under this Employer’s Plan has medical coverage through one of these types of plans.
If this form is not completed and returned, claims will be pended until this information is received.
EMPLOYEE / Date of Birth:OHI: / ___Yes ___ No / If yes, please provide the following information: /
OHI Policy Holder Name: /
Policy Holder’s Date of Birth:
OHI Policy Holder relation to Employee: / __Self, ___Spouse,
__ Parent, __Other (_____) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Over 65 ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
SPOUSE’S NAME: / Date of Birth:
\
Spouse’s Employer: / Employer’s Phone Number: / Does Employer offer Health Care coverage: / ___Yes ___ No
OHI: / ___Yes ___ No / If yes, please provide the following information: /
OHI Policy Holder Name: /
Policy Holder’s Date of Birth:
OHI Policy Holder relation to Employee: / __Self, ___Spouse,
__ Parent, __Other (_____) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Over 65 ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
Please mail or fax completed forms to: Ekon Benefits, 4940 Washington Blvd, St. Louis, MO 63108. Fax: (314) 367-7982.
Please attach a copy of the ID card and/or certificates of creditable coverage for any other insurance plans. Creditable Coverage may be applicable under this plan. Please provide the Certificate of Creditable Coverage with this form, if possible. If received at a later time, provide a copy to your employer or Med-Pay as soon as received.
Please notify Med-Pay immediately if any of this information changes, (417) 886-6886 or (800) 777-9087.
Employee Signature Date
(Continued on page 3- OHI Form- Dependent Children)
Page 3 (OHI Form- Dependent Children)
CHILD #___: NAME: /
Date of Birth:
Relation to Employee: / __Natural Child, __Step-Child, __Adopted Child, __Foster Child, __ Under Legal Guardianship
Child’s Address if different than Employee’s:
If dependent child over 19, is he/she a full-time student? / ___Yes
___ No / If yes, please provide a statement from the college or university stating full-time or part-time status for the Spring, Fall or both semesters. Failure to provide information could lead to a lapse in coverage.
If dependent child is over 19, is he/she eligible for employer-sponsored health care coverage through his/her own employer or his/her spouse’s employer? / ___Yes ___ No
OHI: / ___Yes ___ No / OHI Policy Holder Name: / Policy Holder’s Date of Birth:
OHI Policy Holder relation to Dependent: / __Self, __ Parent,
__Spouse,
__Other (______) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
Mother’s Name, Address & Phone No.:
Father’s Name, Address & Phone No.:
**Are the Child’s Parents __Separated, __Divorced, __Never Married or
__Other (______)? / Who has physical custody?
CHILD #___: NAME: /
Date of Birth:
Relation to Employee: / __Natural Child, __Step-Child, __Adopted Child, __Foster Child, __ Under Legal Guardianship
Child’s Address if different than Employee’s:
If dependent child over 19, is he/she a full-time student? / ___Yes
___ No / If yes, please provide a statement from the college or university stating full-time or part-time status for the Spring, Fall or both semesters. Failure to provide information could lead to a lapse in coverage.
If dependent child is over 19, is he/she eligible for employer-sponsored health care coverage through his/her own employer or his/her spouse’s employer? / ___Yes ___ No
OHI: / ___Yes ___ No / OHI Policy Holder Name: / Policy Holder’s Date of Birth:
OHI Policy Holder relation to Dependent: / __Self, __ Parent,
__Spouse,
__Other (______) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
Mother’s Name, Address & Phone No.:
Father’s Name, Address & Phone No.:
**Are the Child’s Parents __Separated, __Divorced, __Never Married or
__Other (______)? / Who has physical custody?
Please mail or fax completed forms to: Ekon Benefits, 4940 Washington Blvd, St. Louis, MO 63108. Fax: (314) 367-7982.
(Continued on page 4- OHI Form- Dependent Children)
Rev 8/2010
Page 4 (OHI Form- Dependent Children)
EMPLOYEE LAST NAME: / FIRST NAME: / M.I. / SOCIAL SECURITY NUMBER:CHILD #___: NAME: /
Date of Birth:
Relation to Employee: / __Natural Child, __Step-Child, __Adopted Child, __Foster Child, __ Under Legal Guardianship
Child’s Address if different than Employee’s:
If dependent child over 19, is he/she a full-time student? / ___Yes
___ No / If yes, please provide a statement from the college or university stating full-time or part-time status for the Spring, Fall or both semesters. Failure to provide information could lead to a lapse in coverage.
If dependent child is over 19, is he/she eligible for employer-sponsored health care coverage through his/her own employer or his/her spouse’s employer? / ___Yes ___ No
OHI: / ___Yes ___ No / OHI Policy Holder Name: / Policy Holder’s Date of Birth:
OHI Policy Holder relation to Dependent: / __Self, __ Parent,
__Spouse,
__Other (______) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
Mother’s Name, Address & Phone No.:
Father’s Name, Address & Phone No.:
**Are the Child’s Parents __Separated, __Divorced, __Never Married or
__Other (______)? / Who has physical custody?
CHILD #___: NAME: /
Date of Birth:
Relation to Employee: / __Natural Child, __Step-Child, __Adopted Child, __Foster Child, __ Under Legal Guardianship
Child’s Address if different than Employee’s:
If dependent child over 19, is he/she a full-time student? / ___Yes
___ No / If yes, please provide a statement from the college or university stating full-time or part-time status for the Spring, Fall or both semesters. Failure to provide information could lead to a lapse in coverage.
If dependent child is over 19, is he/she eligible for employer-sponsored health care coverage through his/her own employer or his/her spouse’s employer? / ___Yes ___ No
OHI: / ___Yes ___ No / OHI Policy Holder Name: / Policy Holder’s Date of Birth:
OHI Policy Holder relation to Dependent: / __Self, __ Parent,
__Spouse,
__Other (______) / Type of Coverage: / ___Active ___Medicare
___Retiree ___Medicaid
___COBRA / *OHI Effective Date
(If Medicare, include Part A & B dates):
If Medicare coverage, reason for coverage: / ___ Disabled ___ End Stage Renal Disease ___ Other ______
OHI Policy Holder’s Employer: / Group Number: / Policy ID Number:
OHI Policy Holder’s Address:
OHI Carrier Name, Address & Phone Number:
Mother’s Name, Address & Phone No.:
Father’s Name, Address & Phone No.:
**Are the Child’s Parents __Separated, __Divorced, __Never Married or
__Other (______)? / Who has physical custody?
Please mail or fax completed forms to: Ekon Benefits, 4940 Washington Blvd, St. Louis, MO 63108. Fax: (314) 367-7982.
If necessary, make copies and attach additional pages of this OHI Form for more dependent children.
* Please attach a copy of the ID card and/or certificates of creditable coverage for any other insurance plans. Creditable Coverage may be applicable under this plan. Please provide the Certificate of Creditable Coverage with this form, if possible. If received at a later time, provide a copy to your employer or Med-Pay as soon as received.
** If “yes”, please attach/send a copy of the following portions of the separation agreement/divorce decree: a) the first page which identifies the petitioner and respondent; b) any pages that reference custody and insurance; and c) the judge’s signature page (usually the last page of the document). Note: Please be sure to include these same pages for any attachments (i.e., parenting plan, separation agreement, etc.) that is referenced in the decree.
Please notify Med-Pay immediately if any of this information changes, (417) 886-6886 or (800) 777-9087.
Employee Signature Date
Rev 8/2010