Medical, Dental, and Vision Enrollment Change Form

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Medical, Dental, and Vision Enrollment Change Form Powered By Docstoc
					                                                                                                                                           Appt %: ________         BCAT: ______________
                                                  MEDICAL/ DENTAL/ VISION                                                                  Annualized Salary: <35          35-50  >50
                                                ENROLLMENT / CHANGE FORM                                                                   Coverage starts 1st of next month:______________
                                        Changes are effective the 1st of the next month following receipt of forms by HR                   Coverage starts immediately: _________________
                                                         Visit                                              Deduction starts: _________________________
                                                                 for details and required documentation                                                       HR USE ONLY

Employee Information
Name (Last, First, MI)                                                                                         Date of Birth                UNM Banner ID (Employee ID- 9 digits)

Address                                                                                                        Gender                       Marital Status
                                                                                                                         Male                         Married
                                                                                                                         Female                       Single
                                                                                                                                                      I have a Domestic Partner
                                                                                                                                                 Note: Copy of Marriage Certificate or Domestic
Note: Your mailing address and preferred email address in LoboWeb is used for                                                                    Partner Affidavit will be required.
Benefits enrollment records and communications. It is imperative that you review                               Date of Hire                 Is your spouse a UNM Employee? (if applicable)
and update your demographic information in LoboWeb in a timely manner.                                                                           Yes Spouse’s Name:

Type of Action (See for required documentation and eligibility details)
    ENROLL                                                               CANCEL                                        ADD                                       CANCEL
(documentation required, see page 2)                                     COVERAGE                                      DEPENDENT(S)                              DEPENDENT(S)
          Newly Benefit Eligible – Electing Coverage Effective     (documentation required, see page 2)         (documentation required, see page 2) (documentation required, see page 2)
           Immediately - premiums not prorated (within 60                 Qualifying Life Event - (within 31           Qualifying Life Event -(within
                                                                          calendar days of change)                     31 calendar days)                     Divorce/Separation
           calendar days of new eligibility)
          Newly Benefit Eligible – Electing Coverage Effective             LWOP -(within 31 calendar days              Birth of Child – (within 31           Dependent Ineligible (age)
           First of Following Month (within 60 calendar days               of leave begin date)                        calendar days of birth)               Qualifying Life Event -
           of new eligibility)                                             Newly covered under other                  Other                                   (within 31 calendar days)
           Qualifying Life Event – (within 31 calendar days of              group plan- (within 31 calendar                                                  Other
           event)                                                           days of effective date of other             List Dependent(s) Below
          Return from LWOP (within 31 calendar days from                    coverage)                                                                            List Dependent(s) Below
           return to work date-Reinstatement of prior                      Death
           coverage only)

UNM Medical Plan Third Party
Administrator Election                                             Dental Plan Election                                              Vision Plan Election
   Lovelace Health Plan                                                Delta Dental Premier (High)                                       Vision Service Plan (VSP)
   Presbyterian Health Plan                                            Delta Dental PPO (Low)
                                                                                                                                           Employee Only (Single)
        Employee Only (Single)                                           Employee Only (Single)
                                                                                                                                           Employee + 1 (Double)
        Employee + Child(ren)                                            Employee + 1 (Double)
                                                                                                                                           Family (Employee, spouse/domestic partner,
        Employee + Spouse (or Domestic Partner)                          Family (Employee, spouse/domestic partner, child(ren))
        Family (Employee, spouse/domestic partner, child(ren))

   Enrollees/                                                                                                           Gender           Action:                Mark Type of Coverage
                                                 Name (Last, First, MI)                              DOB
  Dependents                                                                                                             M/F         (Add or Remove)              for each Enrollee
Spouse                                                                                                                                    Add     Remove        Medical     Dental      Vision
Child                                                                                                                                     Add     Remove        Medical     Dental      Vision
Child                                                                                                                                     Add     Remove        Medical     Dental      Vision
Child                                                                                                                                     Add     Remove        Medical     Dental      Vision
Domestic Partner (DP)                                                                                                                     Add     Remove        Medical     Dental      Vision
DP Child                                                                                                                                  Add     Remove        Medical     Dental      Vision
DP Child                                                                                                                                  Add     Remove        Medical     Dental      Vision

Employee Certification
If you knowingly make a false statement on your enrollment Application or file a false claim, such Application or claim may be rescinded retroactively back to the date of the
Application or claim. Any premiums collected from the Participant for coverage that is later revoked due to a fraudulent Application may be refunded to the Participant by the
Plan. If a claim is paid by the Plan and it is later determined that the claim should not have been paid due to a fraudulent Application or claim, the Participant may be
responsible for full reimbursement of the claim amount to UNM.
I understand that my signature authorizes the University of New Mexico to make any necessary deductions from my pay through payroll deduction.
Signature                                                                                                                         Date:
      It is your responsibility to review your Benefits Statement in LoboWeb and your benefit deductions. Report any issues or discrepancies to 277-MyHR (6947).

  See page 2 for instructions on submitting required verification documents with this enrollment form. Failure to
  provide proof documentation may delay the processing and effective date of enrollment of your dependent(s).


               Use the chart below to determine acceptable proof documentation. Submit a copy of the proof
                documents, and make sure official seals are clear and visible. If applicable, you should not submit an
                original document or a certified copy (which would have a raised seal), unless requested.
               Write your UNM Banner ID Number (all 9 digits) on each proof document you submit.
               Make copies of each proof document you submit for your records.

            Please submit proof documents to the UNM HR Service Center

            FAX: Fax all pages to the Employee Benefits Office at 505-277-2278. Keep your successful
            transmission page as proof of documents submitted.

            MAIL: UNM HR Service Center, MSC01 1220-Benefits, 1 University of New Mexico, Albuquerque, NM

            Caution: Interoffice delivery is not recommended, your personal information is not secure and receipt of
            forms is not guaranteed.
            If you have questions call HR Service Center for assistance at 505-277-MYHR (6947) during business
            hours, Monday- Friday, 8:00 am – 5:00 pm.

Spouse (Legally Married)                           Marriage Certificate
Domestic Partner                                   UNM Affidavit of Domestic Partnership form, and three proof documents
                                                   showing shared financial obligations, see UNM policy #3790 for examples
Biological Child                                   Birth Certificate of Biological Child, if Birth Certificate is not available for
                                                   newborn children, proof of birth from provider/hospital listing both parents and
                                                   date of birth is acceptable.
Adopted Child or Child Placed for                  Documentation depends on stage of adoption process.
Adoption                                           Official court/agency placement papers for child placed with you for adoption,
                                                   or Official Court Adoption Agreement for an adopted child, or Birth Certificate
Stepchild                                          Child’s Birth Certificate stating the child’s parent is the employee’s spouse, and
                                                   Marriage Certificate for legal marriage between employee and the child’s parent
Legal Guardianship                                 Court papers demonstrating legal guardianship

Child of Domestic Partner                          Child’s Birth Certificate showing the child’s biological or adoptive parent.
                                                   UNM Affidavit of Domestic Partnership form, and three proof documents
                                                   showing shared financial obligations
                                                   Court document showing that you and your partner have legal custody of
                                                   the child, if the child is not biological or adopted

Disabled Child Age 26 or Older                     UNM Child Disability Affidavit form signed by the employee and the Child’s
                                                   attending Physician. Note: To be eligible for benefit, the disabled dependent must
                                                   be enrolled prior to turning age 26.
To view detailed Eligibility and Enrollment information, please go to

                                                                                                                                 Last Updated June 8, 2012

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