Participant Status Change Form

Type of Change
Name Change Delete Disability Coverage
Address Change Delete Health Coverage
Add Dependent Delete Dental Coverage
Delete Dependent Delete Life Coverage
Terminate Coverage Other: 
EFFECTIVE DATE OF CHANGE: 

Type of Coverage Requested
Employee Health & Life
Employee/Spouse Health Only
Employee/Child(ren) Life Only
Employee/Family Dental
    Disability  

Reason For Change
Marriage ** Overage Dependent
Death ** Layoff
Terminate Employment ** Leave of Absence
Divorce ** Return of Alternate Insurance
Birth ** Disability
Adoption ** Other: 
** DATE OF EVENT: 

General Information
Employer Name Group Number
Employee's Name (Last Name, First Name, Middle Initial) Employee Social Security Number

List of Eligible Dependents To Be Covered A copy of the court order must be attached for dependents in court-ordered custody or guardianship of the Employee.

Additions

First Name and Middle Initial Last Name (if not the same)

 Social Security
Number

Sex

Birth Date

Disabled

 Check if: Declination of Coverage
Add
Spouse
M
F
Yes
No
Supported
by you		 Living
with you		 Full-Time/
Part-Time
Student
Health
Life
Disability
Add
Dependent
Child
M
F
Yes
No
Yes
No
Yes
No
Yes
No
Health
Life
Disability
Add
Dependent
M
F
Yes
No
Yes
No
Yes
No
Yes
No
Health
Life
Disability

Deletions And/Or Changes to Coverage

Name(s) to be deleted (Last, First, Middle Initial) Date of Birth
Reason for Deletion: Age Divorce Marriage Death
Other: 
Name(s) to be deleted (Last, First, Middle Initial) Date of Birth
Reason for Deletion: Age Divorce Marriage Death
Other: 
Change in Beneficiary (Last, First, Middle Initial) Date of Birth Relationship
Add
Delete
Change in Beneficiary (Last, First, Middle Initial) Date of Birth Relationship
Add
Delete
Name
Change
Change From: Change To:
Address
Change
New Address (Street, City, County, State, Zip) Phone
Other

OTHER CARRIER LIABILITY INFORMATION – THIS SECTION MUST BE COMPLETED
On the day this coverage begins, will you or any dependants enrolling in this Plan be covered by any other group insurance or Medicare? Yes No

If yes, fill out the appropriate section(s) below.
Health
Insured Member's Name Date of Birth
Employment Status Name of Employer
Active Retired
Policy # Effective Date
Type of Coverage
Single Family
Name of Insurance Company Phone
City, State and Zip Code of Claims Center
Does the above insurance cover “all” family members including yourself?
Yes No If no, please list the names of all dependents not covered?
Dental
Insured Member's Name Date of Birth
Employment Status Name of Employer
Active Retired
Policy # Effective Date
Type of Coverage
Single Family
Name of Insurance Company Phone
City, State and Zip Code of Claims Center
Does the above insurance cover “all” family members including yourself?
Yes No If no, please list the names of all dependents not covered?

Medicare
Beneficiary Name
Entitlement Reason
Age 65 or older
End Stage Renal Disease
Other Disability
Medicare HIC Number
Part A Effective Date
Part B Effective Date
Beneficiary Name
Entitlement Reason
Age 65 or older
End Stage Renal Disease
Other Disability
Medicare HIC Number
Part A Effective Date
Part B Effective Date

I certify that the above information is complete and true and that those listed as such are legal dependents. I also authorize payroll deduction(s) from my salary for my contribution toward the cost of any of the Plan coverages. Pre-existing conditions will not be covered for twelve to eighteen months unless proof of continuation of medical coverage is provided. Any person who knowingly and with intent to injure, defraud, or deceive any benefit plan, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree



PRIVACY/CONFIDENTIALITY NOTE:  The information contained on this form is legally privileged and confidential.  It is intended only for the use of the employer and/or claims administrator.  If you are not the intended recipient of this form, you hereby are notified that any dissemination, distribution, downloading or copying of the contents is strictly prohibited.  If you are the intended recipient(s) you will need to secure the contents conforming to all applicable state and/or federal requirements relating to the privacy and confidentiality of such information, including the HIPAA Privacy guidelines.  FBA does not accept any liability for any errors or omissions in the contents of this form.


A COPY OF THIS COMPLETED FORM SHOULD BE RETAINED FOR YOUR FILES AND THE ORIGINAL RETURNED TO YOUR HUMAN RESOURCES OFFICE OR YOUR BENEFITS ADMINISTRATOR