Transcription of State Health Benefits Program (SHBP) STATE ACTIvE …
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State Health Benefits Program (SHBP) STATE ACTIvE …
1. EMPLOYEE INFORMATION Last Name First MI_____ Gender Birth Date Social Security Number Marital Status*_____ Telephone Number Personal E-mail Address_____Home Address No. and Street Name_____ City STATE Zip 2. EMPLOYMENT STATUS o Full Time o Part Time o Intermittent o National Guard o ACA (monthly only) 3. REASON FOR APPLICATION (check one) o New enrollment o Transfer o Open enrollment o Loss of Coverage o Adding Dependents o Deleting Dependents o Waiver of Coverage o Other Reason_____ Date of Event _____/_____/_____State Health Benefits Program (SHBP) STATE ACTIvE EMPLOYEE gROUPhEALTh Benefits enrollment and/or ChANgE FORMHA-0891-0617 5.
INSTRUCTIONS FOR ThE ShbP STATE ACTIvE EMPLOYEE gROUP hEALTh bENEFITS ENROLLMENT and/or ChANgE FORM SECTION 1 – EMPLOYEE INFORMATION – Complete entire section. Indicate Marital Status as …
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