If YES is indicated for either of the rejection questions, the entire section must be completed along with Section 9 - Other Insurance Information. In most cases, the group will sponsor only the benefit plans enrolled by the group. Check the applicable box. A description of each contact type can be found in the Section II - Eligibility. Check the continuation eligibility section, only if applicable.
Detailed information regarding continuation eligibility is included in Section II - Eligibility.
If the employee wants coverage for his or her spouse, complete this section by entering the spouse's name, date of birth, and sex. Eligibility criteria for spouses can be found in Section II - Eligibility. Legal documentation is required for any child residing with the employee in a relationship other than a natural child. This section is completed if the employee elects either the Med Point sm or Personal Care Plan sm benefit plan. The section must be completed for the employee and each dependent to be covered.