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Oklahoma State _ Education Employees Group Insurance Program

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					                                                 OPSU ENROLLMENT/CHANGE FORM




  EMPLOYEE INFORMATION – Please Print


Campus Wide ID: ___ ___ ___ ___ ___ ___ ___ ___              Social Security #: ___ ___ ___ - ___ ___ - ___ ___ ___ ___    Gender: M F



Employee Name: __________________________________                       Married     Single     Divorced      Widowed       Common Law



Home Telephone:_____________________________________                      Campus Telephone:____________________________________



Mailing Address:________________________________________________________________________________________________



City:_____________________________ State:_________Zip: ________________________ Email: _____________________________



          Birth Date: __ __ / __ __ / __ __ __ __ Date of Hire __ __ / __ __ / __ __ Effective Date __ __ / 01 / 20__ __




  HEALTH PLAN - BLUECROSS BLUESHIELD                                                          ADD        DROP NO CHANGE
  specialty drugs
 BlueChoice PPO



  DENTAL PLAN - STATE INSURANCE BOARD                                                         ADD        DROP            NO CHANGE

 HealthChoice


  VISION PLAN - STATE INSURANCE BOARDADD                                       DROP            NO CHANGE


 Vision Service Plan (VSP)




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  DEPENDENT INFORMATION

SPOUSE:       Name:      ________________________________________                          SSN:__________________________                   ADD         DROP

              Date of Birth: _____________Date of Marriage: _____________ Date of Death: ________________                                                       Health
                                                                                                                                                                Dental
              Address        (Check if same as employee):_______________________________________________                                                        Vision

              Gender: M F                                                 Primary Dentist (Prepaid): _______________________________

CHILD:        Name:      ________________________________________                          SSN:__________________________                   ADD         DROP

              Date of Birth: _____________ Date of Death: ________________                                                                                      Health
                                                                                                                                                                Dental
              Address        (Check if same as employee):_______________________________________________                                                        Vision

              Gender: M F                                                 Primary Dentist (Prepaid): _______________________________

CHILD:        Name:      ________________________________________                          SSN:__________________________                   ADD         DROP

              Date of Birth: _____________ Date of Death: ________________                                                                                      Health
                                                                                                                                                                Dental
              Address        (Check if same as employee):_______________________________________________                                                        Vision

              Gender: M F                                                 Primary Dentist (Prepaid): _______________________________

CHILD:        Name:      ________________________________________                          SSN:__________________________                   ADD         DROP

              Date of Birth: _____________ Date of Death: ________________                                                                                      Health
                                                                                                                                                                Dental
              Address        (Check if same as employee):_______________________________________________                                                        Vision

              Gender: M F                                                 Primary Dentist (Prepaid): _______________________________


 CERTIFICATION SIGNATURES

SPOUSE MUST SIGN IF SPOUSE IS EXCLUDED FROM DENTAL COVERAGE
    SPOUSE EXCLUSION CERTIFICATION: I certify that I am aware I am being excluded from Dental coverage as indicated on this form. I am also aware
    that an employee who elects to cover all eligible dependent children and NOT their spouse will not have the opportunity to enroll his/her spouse until either the next
    option period or a change of status event occurs.


Spouse Signature:                                                                                                       Date:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    COMMON LAW SPOUSE CERTIFICATION: I certify the person listed is my spouse and we have an actual and mutual agreement between ourselves
    to be husband and wife; this is a permanent relationship; and our relationship is exclusive, as proven by our cohabitation as man and wife; and do hereby
    hold ourselves out publicly as husband and wife. I am aware this relationship can only be dissolved by legal divorce. (Common Law spouses can only
    be enrolled at initial enrollment or Annual Enrollment.)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    I certify this enrollment is in compliance with the provisions of the employer’s Section 125 Plan or, if no 125 Plan is offered, is in compliance with new hire
    or allowed mid-year coverage enrollments as defined by Title 26, Section 125, of the Internal Revenue Codes (as amended), and pertinent regulations.
    I agree to deliver documentation which authenticates this statement to the requesting entity upon request. I hereby authorize, by my signature below, the
    release of all medical records necessary to the Health Plan selected on this form.
    I authorize my employer to deduct from my pay the premium, if any, for the elected coverage. I understand that In the event in which I do not receive pay,
    premiums will be billed to my bursar account and are subject to cancellation for non-pay.


EMPLOYEE SIGNATURE:                                                                                                     DATE:



   If this is a mid-year change request please complete the attached Section 125 form to identify the qualifying event.
OSU Human Resources USE ONLY:
Received by: ________________Date:_______________                                              Coded by: ________________Date:_______________

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                                  PLAN GUIDELINES FOR ELECTION CHANGES
                                                      Detach and retain for your Records
   IMPORTANT – YOU MUST READ THE FOLLOWING PLAN GUIDELINES BEFORE COMPLETING FORM
          Signatures on your form certify that you have read this page and that all of your elections meet the plan Guidelines.
                                    Refer to Title 74 Oklahoma Statutes §1323, Fraud - Penalties

BlueCross BlueShield
There is a Preexisting Condition limitation on the coverage available from the BlueCross BlueShield (BCBS) Health Plan. A Preexisting
Condition is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or
treatment was recommended or received within the six-month period ending on the enrollment date.
A Preexisting Condition will not apply to pregnancy or to a newborn or adopted child under age 18, provided the child becomes covered under
the Contract/Agreement within 31 days of birth or adoption. The length of the Preexisting Condition limitation period is 12 months after the
enrollment date for Timely and Special Enrollees, and 18 months for Late Enrollees. The Preexisting Condition limitation waiting period may
be reduced by the number of days you (and/or your spouse, and/or dependents) were covered under a prior health insurance plan(s) should
there be no more than a 63-day break in coverage. To do this you may request a Certificate of Coverage form from the prior health plan(s) or
issuer and send it to The Enrollment Services Department at BCBS. After the amount of prior creditable coverage has been determined, we
will notify you of Preexisting Condition credit based on your prior coverage.

Changing or adding coverage for yourself and your dependents:
Mid-Year Changes: To be eligible to add, drop, or change coverage on yourself and/or your dependents subsequent to your initial
employment (other than Option or Annual Enrollment), you must have experienced a Qualifying Event and, you must make your elections and
sign the form within 31 days of the Qualifying Event.

Strict consistency rules apply to all Qualifying Events. A benefit election change is only consistent with a Qualifying Event if the election
changes are necessary or appropriate as a result of the event, i.e. adding Health coverage (benefit election change) is NOT consistent with the
loss of a dependent child (Qualifying Event.) Allowable Mid-Year Changes within Plan guidelines include:
          -   Change in your legal marital status
          -   Change in your number of dependents
          -   Change in your, or your dependents employment status that directly effects eligibility
          -   An event that causes your dependent to satisfy, or cease to satisfy eligibility requirements (over age limit, student status, etc.)
          -   Changes in your, or your dependents, place of residence that directly effects eligibility or HMO/DMO availability
          -   Leaving on or returning from FMLA Leave, Leave Without Pay, USERRA Leave, Disability Leave

Changes that do not fall into the above categories are generally not allowed except at Option or Annual Enrollment. If in doubt as to whether
you qualify for a change, please contact your Insurance Coordinator.

Dropping coverage for yourself or your dependents:
After 12 months you may regain coverage (if requested within 30 days of the end of the 12 month period), but you will be subject to preexisting
conditions and/or dental limitations.

You must be enrolled in group health coverage in order to be eligible for dental coverage through the Oklahoma State and Education
Employees Group Insurance Board. You may exclude BlueCross BlueShield health coverage if you have other verifiable group health
coverage. You will be asked to provide proof of your coverage on the Waive OSU-Paid Health Insurance for 2009. Failure to provide proof
when requested will result in termination of all coverage.

To be eligible for coverage, a child must be unmarried and under the age of 26 for health coverage and under the age of 25 for vision and
dental coverage. It is your responsibility to notify your Insurance Coordinator when your child is no longer a dependent, marries, or
otherwise becomes ineligible. Neither BlueCross BlueShield nor the State Insurance Board (dental/vision) will pay claims on
ineligible dependents even if you have paid premiums for that dependent.

Your dependents are not eligible for any coverage in which you are not enrolled.

If you cover one child for any given benefit, you must cover all of your children for that benefit. You may only exclude children who have other
verifiable group coverage and you may be asked to provide proof of that coverage. Failure to provide proof when requested will result in
disqualification of your covered dependents.

You may cover your children and exclude your spouse from health and/or dental. If you choose this option, your spouse must sign and date
the spouse certification on this form.

You may cover your children and exclude your spouse from vision coverage, only if your spouse has other verifiable group vision coverage.
You may be asked to provide proof of that coverage. Failure to provide proof when requested will result in termination of all coverage.

Common-law spouses may only be added upon initial employment or at Option or Annual Enrollment. Once publicly declared, a common law
relationship can only be dissolved by legal divorce.




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