Insurance Enrollment / Change Form by 7W35dSZP


									                          KAISER PERMANENTE ENROLLMENT/CHANGE FORM
                                          AURORA PUBLIC SCHOOLS HMO PLAN GROUP #00172-001-01

      A: Date of Hire: __________________________ Effective Date: ________________________
      Employee Name:
                                (Last)                                          (First)                              (MI)

      Employee Date of Birth: ______________________ Employee SSN:

      Employee Address
                                         (Street)                                     (City)                                         (State)       (Zip)

      Employee Phone Number: (                            )

      B:  New            Reason:                                                          Add Spouse                 Cancel Employee
          Change         ______________                                                   Add Child(ren)              Cancel Spouse/DP
          Name Change    ______________                                                   Add DP                      Cancel Child(ren)
          Previous Name                                                                         Common Law and Domestic Partners require
                                                                                                additional affidavits from Benefits Office
      C: Coverage Level
         Employee Only  Employee/Spouse  Employee/Children  Employee/Family
                         Employee/Domestic Partner  Employee/Domestic Partner/Family
             I would like to add or delete coverage for myself and
                                                                                                          SS#               Kaiser         Date of Birth     M/F
                           the following dependents:
                                                                                                       (REQUIRED)            ID#
                                         Last Name                 First Name                  MI

Add      Delete    Employee


                   Domestic Partner






        *Note: Dependents may be covered through the month they turn 26.

                                                                          Pretax Premium
E: Every district employee electing to enroll in medical and/or dental insurance is automatically enrolled in the Pre-tax option. Enrollment
in this plan deducts monthly premiums from an employee’s paycheck before taxes and PERA.

If you are within four years of retirement, you may want to consider waiving participation in the pre-tax option. Participation may impact
your PERA HAS. Please contact the Benefits Office.

 It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting
 to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an
 insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
 or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
 Colorado Division of Insurance within the Department of Regulatory Agencies.

F: Employee Signature: ________________________________________ Date: _______________________________

                                                                                                                                               Form APSKP1

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