Gem State Developmental Center COBRA Addition

Note: This form is completed when there is a "New Hire" to your Employer Benefits Plans.

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Employer Information

Hire Date**

Effective Date**

Enrolled In (Check all that apply)**

Medical

Dental

Vision

Medical Plan Enrollment**

Medical Enrollment**

Dental Plan Enrollment**

Dental Enrollment**

Vision Plan Enrollment **

Vision Enrollment **

Form Attachments

Click on "Browse" to Attach Medical Form.

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Maximum file size 10MB (pdf, jpg or jpeg formats only)

Click on "Browse" to Attach Dental Form.

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Maximum file size 10MB (pdf, jpg or jpeg formats only)

Click on "Browse" to Attach Vision Form.

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Maximum file size 10MB (pdf, jpg or jpeg formats only)

Employee Information

First Name**

M.I.

Last Name**

Gender**

Male

Female

Social Security Number**

Date of Birth**

Marital Status**

Home Address**

City**

Zip Code**

Best Contact Number**

Spouse/Dependent(s) Information

Note: When entering spouse and/or dependent(s) information, you MUST under IRS regulations enter their Full SSN and DOB. If this information is not provided, we CANNOT process claims for a spouse and/or dependent(s) under IRS regulations.

Add Spouse?

Yes

Spouse

Relationship**

First Name**

M.I.

Last Name**

Gender**

Male

Female

SSN**

Date of Birth**

Enrolled In (Check all that apply)?**

Medical

Dental

Vision

Add Dependent(s)**

Yes

Notes

Group Contact Email**

Signature of Group Contact Person**

Date of Signature

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Gem State Developmental Center COBRA Addition