State of Michigan Civil Service Commission




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CS-1777

Rev 5/2011



State of Michigan

Civil Service Commission



Employee Benefits Division

400 South Pine Street, P.O. Box 30002

Lansing, Michigan 48909





Please type or print FIRMLY with ballpoint pen.

Enrollment Application

Health, Dental, Vision, Life, FSA and LTD Plans




EVENT
 Record Change (Check one below)  New Enrollment  Reinstatement

 Marriage  Birth  Divorce  Death  Ineligible Dependent  Other (Explain) Reason:      



DATE OF EVENT

     


SECTION A – APPLICANT DATA

EMPLOYEE ID NO.

     


EMPLOYEE LAST NAME

     


FIRST NAME

     


M.I.

 


ARE YOU OR YOUR SPOUSE ENROLLED IN MEDICARE?

EMPLOYEE  YES  NO

SPOUSE  YES  NO

ARE YOU MARRIED TO A STATE OF MICHIGAN EMPLOYEE OR RETIREE?  YES  NO

IF YES, EMPLOYEE ID NO. AND NAME OF SPOUSE

     


SECTION B – COVERAGE DATA

HEALTH

 New State Health Plan/State Health Plan

 New

HMO/HMO

 Catastrophic
Plan


 Opt Out

W/Refund*

 Decline Coverage

W/O Refund

 E – Employee Only

 S – Employee & Spouse

 C – Employee & Children

 F – Full Family

IF HMO, PROVIDE NAME OF HMO & CODE FROM NEW HIRE BENEFIT ELECTION FORM

     


DENTAL

 State Dental
Plan


 DMO

 Preventive

Dental Plan

 Opt Out

W/Refund*

 Decline Coverage

W/O Refund

 E – Employee Only

 S – Employee & Spouse

 C – Employee & Children

 F – Full Family

VISION

 State Vision Plan

 Decline Coverage

W/O Refund

 E – Employee Only

 S – Employee & Spouse

 C – Employee & Children

 F – Full Family

LIFE

 Reduced Life (One times annual salary to maximum of $50,000)

 Regular Life (Two times annual salary to a maximum of $200,000*)



*This life insurance limit may not be applicable to employees who are covered by a collective bargaining agreement.

Dependent Life Coverage

 F – Spouse $1,500 and/or Child(ren) $1,000

 G – Spouse $5,000 and/or Child(ren) $2,500

 H – Spouse $10,000 and/or Child(ren) $5,000



 K – Spouse $25,000 and/or Child(ren) $10,000

 L – Child(ren) $10,000

 Waive Dependent Life Coverage


FSA

Flexible Spending Account - Health Care Spending Account:

 Enroll Health Care Spending Account

Amt       X Pay Periods    = Annual Goal      

 Waive Health Care Spending Account



Flexible Spending Account - Dependent Care Spending Account:

 Enroll Dependent Care Spending Account

Amt       X Pay Periods    = Annual Goal      

 Waive Dependent Care Spending Account



LTD

 Elect Coverage

 Decline Coverage

 I have read and understand the conditions under which long-term disability can be paid.

SECTION C – DEPENDENT ENROLLMENT DATA (Attach additional pages, if necessary.)

ADD

DEL

NAME LAST FIRST M.I.

SOCIAL SECURITY NUMBER

RELATION TO YOU

SEX
M/F


DATE OF BIRTH
(MM/DD/YYYY)


COVERAGE (Y/N)

HEALTH

DENTAL

VISION

LIFE





SPOUSE      

     

     

 

     

   

   

   

   





DEPENDENT      

     

     

 

     

   

   

   

   





DEPENDENT      

     

     

 

     

   

   

   

   





DEPENDENT      

     

     

 

     

   

   

   

   





DEPENDENT      

     

     

 

     

   

   

   

   





DEPENDENT      

     

     

 

     

   

   

   

   




I have read and agree to the applicable terms and conditions stated on the reverse side of this application

SIGNATURE OF APPLICANT

CONTACT PHONE NUMBER

DATE

A portion of this information is protected by federal and privacy laws and/or state confidentiality requirements.

* If your spouse is a state employee/retiree, cash refunds are not payable.



* Employees hired on or after April 1, 2010 are eligible for the New State Health Plan or New HMO Plan only.

IF THIS IS AN APPLICATION FOR COVERAGE:

  • I certify that the information provided on the front of this application is correct to the best of my information, knowledge, and belief.

  • I elect to enroll in the state-sponsored Health, Dental, Vision, Life, FSA and/or LTD Plan(s) for which I am eligible, as checked on the front of this application. I understand that this application authorizes the State of Michigan to withhold the contribution(s) required for my enrollment(s).

  • I understand that I may enroll my legal spouse (with copy of marriage certificate), and unmarried children under age 19 (with copy of official birth certificate, not hospital birth certificate) or up to age 25 who are enrolled in an accredited educational institution (with copy of school registration or other records proving school attendance). Eligible children include my child by birth, legal adoption, or legal guardianship; foster children placed in my home by a state agency or a court; and step-children for whom I have physical custody (i.e. live with me at least 50% of the time as stated in a current divorce decree and for whom I provide at least 50% of their support). Effective October 3, 2010, eligible adult children up to age 26 may be enrolled in your health coverage.

  • I also understand that coverage(s) which are already in place for my unmarried child will not be terminated at age 19 and over if the child is totally incapacitated, unable to earn a living because of mental or physical disabilities, and depends chiefly on me for support and maintenance, and that coverage(s) are not terminated for any other reason. Proof that your child is incapacitated must be submitted before age 19 to your health plan administrator or to the Employee Benefits Division.

  • I agree to give notice of any changes in my status and status of my family members that effect eligibility. If I acquire a new eligible dependent, plan enrollment must be made either in 31 days of this event (with copy of official birth certificate, not hospital birth certificate, if newborn, marriage certificate, if new spouse, or adoption papers, if newly adopted child), or during an open enrollment period.

  • I understand that no one may be insured as both an employee/retiree AND as a dependent under these state-sponsored plans; nor may two employees/retirees independently insure the same dependent(s) under state-sponsored plans.

  • I authorize the Plan Administrator to obtain from providers of service any and all records and information relating to me and my family members. I understand that this information may also be reviewed by the State of Michigan.

IF I HAVE DECLINED COVERAGE ON THE FRONT OF THIS APPLICATION:

  • I understand that I have been offered enrollment in the state-sponsored Health, Dental, Vision, Life, and/or LTD Plan(s), but have declined coverage in one or all of the plans at this time, as I have indicated on the front of this application.

IF I AM MAKING A RECORD CHANGE ON THE FRONT OF THIS APPLICATION:

  • I certify that the information provided on the front of this application, as it relates to the membership change I’ve requested, is correct to the best of my information, knowledge, and belief.

OTHER:

  • Addresses for dependents can be provided to your MI-HR Human Resources Office, if different than yours.

  • Check with your Human Resources Office for information regarding continuation of coverage for your dependents in the event they become ineligible.

AUTHORIZED DMO DENTAL CENTERS (Choose one center)

CANTON, MI

DEARBORN, MI

DETROIT, MI

LANSING, MI

STERLING HEIGHTS, MI



WARREN, MI

WOODHAVEN, MI


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