Medical, Dental, Vision Enrollment/Changes This form will adjust based on responses provided. "*" indicates required fields Your Name * Required First Last Email * RequiredCan be a Kalamazoo College or personal email address What brings you here today? * Required I am a new employee. I am making my health-related selections. I am a current employee. I need to change my health-related selections. I am or will be a pre-65 retiree. I need to elect or change my health-related selections. Your Birthdate * RequiredMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Social Security Number * RequiredChanges to health, dental, visionThis section includes the ability to change health, dental, and/or vision coverages for yourself and/or your eligible dependents. I understand that I can change my decision during open enrollment or within 30 days of a qualifying event such as marriage, divorce, or a new child.Are you adding or removing coverage? * Required I am adding coverage (health, dental, or vision) I am dropping coverage (health, dental, or vision) Who will be impacted by your change(s)? * Required Me, the employee/retiree named above My spouse/partner My dependent child(ren) Which coverages are you adding? * RequiredSelect one or multiple. Health Dental Vision Select AllWhich coverages are you dropping? * RequiredSelect one or multiple. Health Dental Vision Select AllWhen should this change be effective? * RequiredThe effective date must be within 30 days of completing this form Month Day Year Why are you making this change? * RequiredPer regulation, there are a finite number of reasons for which a change to health, dental, and/or vision can be made outside of the open enrollment period. Lost other coverage Gained other coverage Got married Had a baby, adopted a child, or placed a child for foster care Got divorced or legally separated and lost health insurance Other Upload file(s) to support the requested change. * Required Drop files here or Select files Max. file size: 5 MB, Max. files: 3. New selections for health, dental, visionThis section includes the ability to enroll/decline health, dental, and/or vision. I understand that I can change my decision during open enrollment or within 30 days of a qualifying event such as marriage, divorce, or a new child.Health InsuranceHow do you want to handle health insurance at K? * RequiredYou will get a chance to share your dental and vision decisions shortly. I want Kalamazoo College’s health insurance. I am declining Kalamazoo College’s health insurance. In addition to electing health insurance for yourself, is there anyone else for whom you would like to provide health insurance? * Required I need to cover my spouse/partner. I need to cover my child(ren) who are age 26 or under. I would like to elect for myself only. DentalHow do you want to handle dental insurance at K? * Required I want Kalamazoo College’s dental insurance. I am declining Kalamazoo College’s dental insurance. In addition to electing dental insurance for yourself, is there anyone else for whom you would like to provide dental insurance? * Required I need to cover my spouse/partner. I need to cover my child(ren) who are age 26 or under. I need to cover myself only. VisionHow do you want to handle vision insurance at K? * Required I want Kalamazoo College’s vision insurance. I am declining Kalamazoo College’s vision insurance. In addition to electing vision insurance for yourself, is there anyone else for whom you would like to provide vision insurance? * Required I need to cover my spouse/partner. I need to cover my child(ren) who are age 26 or under. I need to cover myself only. DependentsSpouse/Partner's Name * Required First Middle Last Spouse/Partner's Name * Required First Middle Last Spouse/Partner's Name * Required First Middle Last Spouse/Partner's Social Security Number * RequiredSpouse/Partner's Date of Birth * Required Month Day Year Spouse/Partner's Sex * Required Female Male Non-binary Spouse/Partner's Social Security Number * RequiredSpouse/Partner's Date of Birth * Required Month Day Year Spouse/Partner's Sex * Required Female Male Non-binary Spouse/Partner's Social Security Number * RequiredSpouse/Partner's Date of Birth * Required Month Day Year Spouse/Partner's Sex * Required Female Male Non-binary Are you legally married to your spouse/partner? * RequiredNon-married partners will need to successfully complete the Affidavit of Domestic Partnership with supporting documentation at https://hr.kzoo.edu/benefits/healthcare/domestic-partner/ I am legally married to my spouse. I am not married to my partner. Kalamazoo College requires spouse/partners who are employed elsewhere to indicate certain pieces of information before Kalamazoo College's coverage can begin. Is your spouse/partner employed? * Required My spouse/partner IS employed and IS eligible for benefits. My spouse/partner IS employed and IS NOT eligible for benefits. My spouse/partner is not employed. Are you legally married to your spouse/partner? * RequiredNon-married partners will need to successfully complete the Affidavit of Domestic Partnership with supporting documentation at https://hr.kzoo.edu/benefits/healthcare/domestic-partner/ I am legally married to my spouse. I am not married to my partner. Kalamazoo College requires spouse/partners who are employed elsewhere to indicate certain pieces of information before Kalamazoo College's coverage can begin. Is your spouse/partner employed? * Required My spouse/partner IS employed and IS eligible for benefits. My spouse/partner IS employed and IS NOT eligible for benefits. My spouse/partner is not employed. What coverages have your spouse/partner elected with their employer? * Required Medical Dental Vision My spouse/partner has declined medical, dental, and vision. Is your spouse/partner's coverage equal or greater than 50%? * RequiredThis means that the insurance covers 50% or more of service costs after the deductible is applied. Yes. Their coverage covers 50% or more of costs. No. My spouse/partner’s coverage covers less than 50% of costs. No. Medical, dental, and vision are not available through my spouse/partner’s employer, if any. What coverages have your spouse/partner elected with their employer? * Required Medical Dental Vision My spouse/partner has declined medical, dental, and vision. Is your spouse/partner's coverage equal or greater than 50%? * RequiredThis means that the insurance covers 50% or more of service costs after the deductible is applied. Yes. Their coverage covers 50% or more of costs. No. My spouse/partner’s coverage covers less than 50% of costs. No. Medical, dental, and vision are not available through my spouse/partner’s employer, if any. Provision for spouse/partner coverage I understand and will ensure that my spouse/partner will enroll in their employer’s health/dental/vision, if required.Insurance carrier and policy number * RequiredProvision for spouse/partner coverage * Required I understand and will ensure that my spouse/partner will enroll in their employer’s health/dental/vision, if required.Insurance carrier and policy number * RequiredWhat is the name of your spouse/partner's employer? * RequiredAddress of Spouse/Partner's employer * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the name of your spouse/partner's employer? * RequiredAddress of Spouse/Partner's employer * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Enter the email address of your spouse/partner to send them a copy of your submission.A copy of your submission will be sent to the employee/retiree named above. How many children are you insuring? * Required One (1) child Two (2) children More than two children How many children are you insuring? * Required One (1) child More than one child Dependent Child's Name * RequiredChild 1 First Middle Last Dependent Child's Name * RequiredChild 1 First Middle Last Dependent Child's Name * RequiredChild 1 First Middle Last Dependent Child's Social Security Number * RequiredChild 1: Enter zeros if the social security number is not assigned yet.Dependent Child's Date of Birth * RequiredChild 1 Month Day Year Dependent Child's Sex * RequiredChild 1 Female Male Non-binary Dependent Child's Social Security Number * RequiredChild 1: Enter zeros if the social security number is not assigned yet.Dependent Child's Date of Birth * RequiredChild 1 Month Day Year Dependent Child's Sex * RequiredChild 1 Female Male Non-binary Dependent Child's Social Security Number * RequiredChild 1: Enter zeros if the social security number is not assigned yet.Dependent Child's Date of Birth * RequiredChild 1 Month Day Year Dependent Child's Sex * RequiredChild 1 Female Male Non-binary Child's Name * RequiredChild 2 First Middle Last Dependent Child's Social Security Number * RequiredChild 2: Enter zeros if the social security number is not assigned yet.Dependent Child's Date of Birth * RequiredChild 2 Month Day Year Dependent Child's Sex * RequiredChild 2 Female Male Non-binary Please provide the requested information for each child in addition to two children. * RequiredInclude for each child: Full name, social security number, date of birth, and sexPlease provide the requested information for each additional child. * RequiredInclude for each child: Full name, social security number, date of birth, and sexAdditional CommentsConsent(s) and Release(s)Authorization for Release of Protected Health Information. * Required Employee/Retiree Release of Protected Health Information.By signing below, as an employee or retiree, I authorize the use or disclosure of my individually identifiable health information by or to any family family member, any health care provider, the Plan Sponsor, the insurer/TPA of the Plan, or any other entity providing services in connection with the Plan in order to process my enrollment in the Plan or to process any claim for my Plan benefits. This authorization is effective until the date I terminate enrollment in the Plan. Further, I have read and understand the following: (1) I may revoke this authorization at any time before its expiration date by notifying the Plan in writing, but the revocation will not have any effect on any actions that Plan took before it received the revocation, (2) I may se and copy the information described on this authorization if I ask for it, (3) I am not required to sign this authorization to receive my health care benefits (enrollment, treatment, or payment), and (4) the information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity.Authorization for Release of Protected Health Information. * Required Spouse/Partner Release of Protected Health Information.By signing below, as an employee or dependent, I authorize the use or disclosure of my individually identifiable health information by or to any family family member, any health care provider, the Plan Sponsor, the insurer/TPA of the Plan, or any other entity providing services in connection with the Plan in order to process my enrollment in the Plan or to process any claim for my Plan benefits. This authorization is effective until the date I terminate enrollment in the Plan. Further, I have read and understand the following: (1) I may revoke this authorization at any time before its expiration date by notifying the Plan in writing, but the revocation will not have any effect on any actions that Plan took before it received the revocation, (2) I may se and copy the information described on this authorization if I ask for it, (3) I am not required to sign this authorization to receive my health care benefits (enrollment, treatment, or payment), and (4) the information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity.Authorization for Release of Protected Health Information. * Required Dependent Child(ren) (age 18+) Release of Protected Health Information, or Parent/Guardian Release if Dependent Child(ren) is/are MinorsBy signing below, as an employee or dependent, I authorize the use or disclosure of my individually identifiable health information by or to any family family member, any health care provider, the Plan Sponsor, the insurer/TPA of the Plan, or any other entity providing services in connection with the Plan in order to process my enrollment in the Plan or to process any claim for my Plan benefits. This authorization is effective until the date I terminate enrollment in the Plan. Further, I have read and understand the following: (1) I may revoke this authorization at any time before its expiration date by notifying the Plan in writing, but the revocation will not have any effect on any actions that Plan took before it received the revocation, (2) I may se and copy the information described on this authorization if I ask for it, (3) I am not required to sign this authorization to receive my health care benefits (enrollment, treatment, or payment), and (4) the information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity. Δ
