Pre-Med Defender Secondary Enrollment Form (2026 State of Oklahoma)

Pre-Med Defender Secondary Enrollment Form (2026 State of Oklahoma)

Please complete this form if you are requesting New Coverage for the remainder of 2026 or if you need to make a Change to your existing 2026 Pre-Med Defender Coverage. Submitting this form is not a guarantee of coverage. Your enrollment will be submitted for processing and once approved, you will receive and email confirmation.
Enrollment Type
Select One
Desired Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearNOTE: NEW HIRE: EFFECTIVE DATE MUST BE THE FIRST OF THE MONTH FOLLOWING THE DATE OF THIS ENROLLMENT. ADDING A DEPENDENT: EFFECTIVE DATE WILL BE FIRST OF THE MONTH. TERMING A DEPENDENT: EFFECTIVE DATE WILL BE LAST DAY OF THE MONTH.
EMPLOYER / DEPARTMENT

Select Your Employer or State Department Below
Employer / Department
Other
If your Employer / Department is not listed, please add here.
Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you currently enrolled in HealthChoice Basic or Basic Alternative Health Plan?
PERSONAL INFORMATION
Full Name

First NameMiddle NameLast Name
Suffix:
Gender:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status:
Mobile Phone Number
Please enter a valid mobile phone number. Mobile phone is used to text you enrollment confirmations.Format: (000) 000-0000.
Email Address
example@example.com
PERSONAL ADDRESS
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
COVERAGE TIER
Coverage Tier (2026 Rates)
DEPENDENT INFORMATION

Please List All Dependents who will be covered on this policy.
Spouse Name

First NameMiddle NameLast Name
Spouse SSN:
Spouse Gender:
Spouse Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 1 Name

First NameMiddle NameLast Name
Child 1 SSN:
Child 1 Gender:
Child 1 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 2 Name

First NameMiddle NameLast Name
Child 2 SSN:
Child 2 Gender:
Child 2 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 3 Name

First NameMiddle NameLast Name
Child 3 SSN:
Child 3 Gender:
Child 3 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 4 Name

First NameMiddle NameLast Name
Child 4 SSN:
Child 4 Gender:
Child 4 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 5 Name

First NameMiddle NameLast Name
Child 5 SSN:
Child 5 Gender:
Child 5 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PAYMENT / DEDUCTION AUTHORIZATION
I authorize payroll deduction for my Pre-Med Defender secondary premiums
DISCLOSURES & ACKNOWLEDGEMENTS
I understand that this form is used to collect the neccessary information for me to enroll or make a change in my Pre-Med Defender supplemental coverage. Completing this form is not an offer of coverage or proof of enrollment. I agree to be contacted via phone / email to verify my enrollment information. A confirmation email will be sent to the email address i have provided once my enrollment / change has been verified and accepted.
I consent to receive electronic communications.
SIGNATURE
E-Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Pre-Med Defender Secondary Enrollment Form (2026 State of Oklahoma)

EMPLOYER / DEPARTMENT

PERSONAL INFORMATION

PERSONAL ADDRESS

COVERAGE TIER

DEPENDENT INFORMATION

PAYMENT / DEDUCTION AUTHORIZATION

DISCLOSURES & ACKNOWLEDGEMENTS

SIGNATURE