Transcription of State Health Benefits Program (SHBP) LOCAL GOVERNMENT ...
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State Health Benefits Program (SHBP) LOCAL GOVERNMENT ...
HA-0889-0819. State Health Benefits Program (SHBP). LOCAL GOVERNMENT ACTIVE EMPLOYEE GROUP. Health Benefits ENROLLMENT and/or CHANGE FORM. 1. EMPLOYEE INFORMATION Last Name First MI DIVISION USE ONLY. Effective Dates Event Reason: _____ H _____ _____ _____. Gender Birth Date Social Security Number Marital Status* Rx _____ _____ _____. / / . _____ EMPLOYER CERTIFICATION. (See Instructions on reverse). Telephone Number Personal Email Address ( ) Employer _____ Name _____. Home Address No. and Street Name Location # ( State Monthly). _____. City State Zip 10/12 - month employee (Enter 10 or 12 ). 2. EMPLOYMENT STATUS o Full Time o National Guard MEMBER ACTION.
EMPLOYEE CERTIFICATION — I certify that all the information supplied on this form is true to the best of my knowledge and that it is verifiable. I understand that if I waive my right to coverage at this time, enrollment is not permissible until the next scheduled open enrollment or if other coverage is lost and proof of loss is provided (HIPAA).
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