Docstoc

CALIFORNIA STATE UNIVERSITY EAST BAY

Document Sample
CALIFORNIA STATE UNIVERSITY EAST BAY Powered By Docstoc
					              CALIFORNIA STATE UNIVERSITY EAST BAY
                  OPEN ENROLLMENT WORKSHEET
Instructions: Please complete all applicable employee and dependent information for each section.
Submit this form to Human Resources Benefits Office, Warren Hall, Room 615, no later than Friday,
October 9, 2009. All Open Enrollment changes will take effective January 1, 2010.

EMPLOYEE INFORMATION (Please print)
Name: ___________________ Social Security Number:_______________________
Address: _____________________ ____________________ _____________
                 Street Address                  City                   Zip Code
Home Phone: _______________________ Birth date: ___________________________
Gender: Male ____Female ____ Marital: Single ___ Married ___ Domestic Partnership ___
Campus Extension: __________ Email ___________________
Department: ___________________________ Position: Staff _______ Faculty ______


OPEN ENROLLMENT SELECTIONS: Health/Dental Coverage
I elect to change my HEALTH PLAN to:
Blue Shield HMO ___ Kaiser HMO ___ PERS Choice PPO ___ PERS Care PPO ___
Blue Shield NetValue HMO* ___ PERS Select PPO* ___

Doctor’s Name: ____________________
(Blue Shield HMO and Blue Shield NetValue ONLY)
*Enrollment based on address

I elect to change my DENTAL PLAN to:
Delta Care USA HMO ___ Delta Dental PPO ___
Family Dental Office choice: ______________________________________________
Dental Group Name & Provider # (DeltaCare/PMI ONLY)

I elect to enroll in the Flex Cash option for: $128 Health__ $12 Dental__
$140 Both__
If your coverage is through your spouse, please list their social security number:
  ____________________
Medial Insurance Company: ______________ Group Number: ____________________
Dental Insurance Company: ______________ Group Number: ____________________
Is your spouse currently employed by a CSU? YES ___ NO ___

*Please note that if electing Flex Cash, you must still provide information in order to enroll
eligible dependents on your Vision Plan

                                PLEASE TURN OVER

                                                
DEPENDENT INFORMATION (Please print)
Please list all dependents you wish to have covered under the appropriate sections below. Please check whether
you want each dependent on medical, dental or both.

SPOUSE ___ or DOMESTIC PARTNER ___
* If enrolling a spouse, a copy of the marriage certificate is required.
** If enrolling a Domestic Partner, submit a copy of the Declaration of State Registration for Domestic Partnership.
__________________________________ ____/____/____ M / F                   _______________________
Full Name of Spous e or Domestic Partner Birth Date Gender                         Social Security Number

Please enroll in:  Medical ____Dental ____ Vision ____

If you are currently being covered as a dependent under another CalPERS sponsored health plan and/or a
State covered dental plan you and/or your family members cannot also be covered under the CSU health and
dental plan(s).
Please answer the following questions:
   1. Is your Spouse/DP currently on a medical/dental plan with a CalPERS/State agency? YES __ NO ___
      If yes, please list the Agency your spouse is working for:
      _______________________________________
   2. If yes, are you/your dependents enrolled on your Spouse’s/DP’s plan? YES ___ NO ___
   3. Are you/your dependent(s) being deleted from this coverage?
      If yes, effective date: _________________

DEPENDENTS (children under the age of 23 years )
If enrolling an Economically dependant child, an Affadavit must be completed.
Name                       Birth Date Relationship Gender Please check applicable Action (circle)
___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

___________________ ___/___/___ ___________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

__________________ ___/___/___ ____________ M / F Medical __ Dental __ Vision __ Add/Delete/NA

I understand that my enrollments in the selected plans are subject to my eligibility. I also understand that I will
be contacted by Human Resources Department to sign official documents once they are processed on my
behalf. I hereby certify that the information provided on this document is true and correct.

______________________________________                               __________________________________
Signature                                                            Date

				
DOCUMENT INFO