Medical, Dental and Vision Enrollment Form Instructions
 

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You are required to fill out the following enrollment forms if electing coverage as follows: 

 

1.      Blue Cross Blue Shield of OR Enrollment Form:  If electing Blue Cross medical coverage.  Answer sections #1, 2.  Fill in other questions if they apply to you and your family.  Sign and date the form. 

 

2.      Kaiser Enrollment Form:  If electing Kaiser medical coverage.  Answer sections #1, 3, 4 & 5 if applicable.  Sign and date your form. 

 

3.      You can waive coverage, but you must sign a waiver form and attach a copy of proof of other coverage.

 

4.      DENTAL PLAN:  Fill out the Blue Cross application online and print.  Make sure you select a dental plan, along with indicating your level of dependents you want   - Employee only (EE only), Employee & 1 dependent or Employee & family.  You must enroll yourself for dental coverage.  You must enroll.  You do not have the option to waive dental coverage.

 

5.      VISION PLAN:  Use the same Blue Cross application and fill out online and print.  Select the coverage level you want – Employee only, Employee & 1 dependent, Employee & family.  You must enroll.  You do not have the option to waive vision coverage.

 

Dependent Information:  Write in the names, sex, dates of birth and Social Security numbers of the dependents you want to enroll in medical, dental and vision coverage. 

• To verify eligibility and help with the administration of the plan, you must provide a Social Security Number for every dependent child age one or older.

• Indicate which plans your dependent(s) should be enrolled in.  Refer to the medical, dental and vision plan information in this Guide for the definition of eligible dependents for each of the plans.

• Child Custody Information:  Complete this information section if applicable.  When parents are divorced or legally separated, insurance regulations stipulate which health plan carrier will be the primary payer (i.e. pays the benefits first) for dependent children.  The carrier covering the person with custody of the child or the person who was given financial responsibility for the health expenses of the children by a court will be the primary payer.

6.       PREVIOUS COVERAGE:  Provide the requested information including medical plan coverage through your current employer, which you may have now, but which will no longer be in effect on or after October 1.

 

7.       OTHER COVERAGE:  Complete this section if you or an enrolled dependent has health coverage through another employer or Medicare.  Leave blank if it does not apply.

 

8.    ADDITIONAL LIFE INSURANCE:  Use The Standard Enrollment Form. 

• To elect $10,000 in Additional Life Insurance coverage, check the Lifestyle Life box.  If for a spouse, check the spouse box.  List your amount of coverage you are requesting. 

• You may apply for coverage for yourself only, for your spouse only, or both.

• You must also submit a completed Medical History Statement.  Coverage is subject to insurance companies approval of the Medical History Statement.

9.   DEPENDENT LIFE INSURANCE: 

• To elect or decline coverage, check the appropriate box.

• When you elect Dependent Life, your spouse and any dependent children are automatically covered.

• Provide names and requested information of family members you are enrolling for life insurance.  (If necessary, attach a sheet with additional names and other information requested.)

10.  BENEFICIARY DESIGNATION FOR LIFE INSURANCE:

• You may designate anyone you want as your beneficiary(s).  However, because of probate, the State of Oregon recommends someone over the age of 18 years old.  Your beneficiary is the person or persons who will receive your Employee Life, Additional Employee Life and Supplemental Life insurance benefits if you die.

• A primary beneficiary is the person who will receive your life insurance benefit if you die.  If you name a contingent, that person will receive payment only if the primary beneficiary dies before you do.

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• If you name two or more primary beneficiaries, you benefit will be divided equally among them all - or you may write in the percentage of the benefit to go to each of your beneficiaries.  (Attach a sheet with additional names and other applicable information, if necessary.)

SIGNATURE: 

• Sign and date the form.

• Return the form to the Benefits Office, or preferably at one of the employee enrollment meetings, via inter-office mail or mail your forms to the Benefits Office.

• Be sure to include any additional forms.

ALL FORMS ARE DUE IN THE BENEFITS OFFICE BY THE 7TH OF THE MONTH BEFORE YOUR BENEFITS START.  (Example:  Benefits start 10/1/07 - applications and forms are due 9/7/07.)