Southwest Kansas Chamber Alliance
HEALTH PLAN ENROLLMENT FORM PLAN #2025
Name of Employer (Also include local chamber affiliation)
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Name
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First Name
Middle Name
Last Name
Social Security Number
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123456789
Date of Birth
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MMDDYYYY
Gender
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Male
Female
Marital Status
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Single
Married
Divorced/Separated
Widowed
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Email
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example@example.com
Date of Full Time Employment
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Eligibility Date
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Coverage You are Enrolling In
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Single
Employee/Spouse
Employee/Child(ren)
Family
Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.
Health Plan Option
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Plan A ($1,000 deductible)
Plan B ($2,500 deductible)
Plan C ($5,500 deductible)
Plan D ($4,000 H.S.A deductible)
Plan E ($7,900 deductible)
Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.
Dental Coverage you are Enrolling In
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Single
EE Child
EE Spouse
Family
Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.
Vision Coverage you are Enrolling In
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Single
EE Child
EE Spouse
Family
Waive**** I, the undersigned, hereby waive eligibility for coverage for myself (and my spouse/dependents). I understand that if I decline coverage during my initial eligibility period, neither me nor my dependents will be eligible for coverage in the future, except under Special Enrollment provisions or Open Enrollment period explained in the group Plan Document.
Covered Dependents (if single coverage put NONE in spouse name)
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Rows
Name
Social Security #
Date of Birth
Gender
Spouse
Child
Child
Child
Child
Child
Child
Child
Child
Will you and/or a member of your family have any other health insurance in addition to the SKCA Health Plan?
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No
Yes
Do you and/or a member of your family have Medicare coverage?
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No
Yes
AUTHORIZATION: I hereby authorize any physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution or person that has any records or knowledge of me or my dependents or my health to give to the Plan Administrator any such information. A photographic copy of this authorization shall be as valid as the original. I understand by enrolling in the Plan I am agreeing to a one year commitment and cannot terminate until the Plan renewal. I understand that any person who knowingly and with intent to defraud any insurance company or other person files an enrollment for insurance or individual health statement containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
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Submit
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