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Single Member Enrolling
Birth Certificate or Driver’s License
Married Member with No Children
Coordination of Benefits Cover Letter
Coordination of Benefits Spouse Employer Form
Birth Certificate or Driver’s License for Member
Birth Certificate or Driver’s License for Spouse
Marriage Certificate
Married Member with Children and/or Stepchildren
Coordination of Benefits Cover Letter
Coordination of Benefits Spouse Employer Form
Birth Certificate or Driver’s License for Member
Birth Certificate or Driver’s License for Spouse
Marriage Certificate
Birth Certificate on all children showing names of both parents
Stepchildren will also need:
- Natural Father Information/Natural Mother Information
- Copy of Spouse’s court documents regarding the stepchildren in its entirety
- Divorce Decree
- Family Court Orders
- Copy of most recent Federal Income Tax Return (Only need page 1 of Federal 1040) showing dependents reside with you
- Written verification from school showing stepchildren reside with you
- In writing please verify the:
- Date of birth of natural parent
- If natural parent is married
- If the natural parent is unemployed (This can be done on the Natural Parent Employer Form, or as part of a written statement)
- With whom the children reside
Single Member with Children
Natural Father Information/Natural Mother Information
Birth Certificate or Driver’s License for Member
Birth Certificate on all children showing names of both parents
Any relevant court documents regarding the children, in their entirety (If none exist, please verify this in a written statement)
- Divorce Decrees
- Separation Agreements
- Family Court Orders
In writing please verify:
- Date of birth of natural parent
- If natural parent is married
- If the natural parent is unemployed (This can be done on the Natural Parent Employer Form, or as part of a written statement)
- With whom the children reside
Divorce Finalized with Spouse
New Enrollment Form
Copy of the entire finalized Divorce Decree (Must include County Clerk Stamp)
- Any referenced other legal documents such as a Separation Agreement
Municipality Enrollment
The only differences from the above documentation needed for municipalities is as follows:
- Enrollment Form for Municipalities instead of generic form
- Enrollment Form Instructions instead of generic form
- Spouse/Dependent Opt Out Form if you would like to not cover them on your insurance
General Health Forms
Eligibility Rules and COB Summary - Eligibility Rules and Coordination of Benefits Summary.
Coordination of Benefits Cover Letter - Cover Letter for Coordination of Benefits Form.
Coordination of Benefits Spouse Form - Form to be submitted for verification of spouse's benefits.
Change of Address- Form to notify the Fund office if you change your mailing address.
Enrollment Form Instructions - Instructions for enrolling for benefits.
Enrollment Form - Form for enrolling for benefits.
Enrollment Form for Municipalities Instructions - Instructions rnrolling Municipal Employees Only.
Enrollment Form for Municipalities - Form for enrolling for benefits. This is for Municipal Employees Only.
Spouse/Dependent Opt Out Form for Municipalities - Opt Out for Municipal Employees Only.
HIPAA Privacy Notice - Notice regarding the Health Insurance Portability and Accountability Act 0f 1996.
HIPAA Authorization Form - Form to release personal information to a third party.
Natural Father Information - Form for Natural Father Employer Coverage.
Natural Mother Information - Form for Natural Mother Employer Coverage.
Rx Reimbursement - COB Claim Form - Form for Prescription COB Claim Reimbursement.
Mail Order Rx Fax Back Form from Provider - Form for Prescription Fax Back from Provider.
Home Delivery Rx Order Form - Form for Mail Order Home Delivery Prescriptions.
Life Insurance Enrollment Form - Enrollment Form for Life Insurance.
