School Employee Forms

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Required Documents for Enrolling Spouses

  • Download and complete the Health Insurance Enrollment Form for your selected provider. Social Security Number (SSN) and Date of Birth (DOB) are mandatory. Forms must be signed and dated by the subscriber.
  • Download and complete Affidavit Form (All marital status questions must be answered and form signed and dated by subscriber
  • Provide a Town or city issued marriage certificate
  • Download the COBRA Rights Notice (signed by subscriber and spouse)
  • Download the HIPPA Notice (no signature required)
  • Download the HSA form if you choose a High Deductible Plan

Documents

Required Documents for Enrolling Children up to Age 26

  • Download and complete Health Insurance Enrollment Form (SSN and DOB are mandatory and form signed and dated by subscriber)
  • Download and complete Affidavit Form
  • Provide Town or city issued birth certificate (long form listing parents names) OR Court Order documenting guardianship OR Adoption papers
  • Download the HSA form if you choose a High Deductible Plan

Documents

Required Documents for Enrolling Divorced or Separated Spouses

  • Download and complete Health Insurance Enrollment Form (SSN and DOB are mandatory and form signed and dated by subscriber)
  • Download and complete Affidavit Form (All marital status questions must be answered and from signed and dated by subscriber)
  • Health Insurance provision language from divorce/separation agreement
  • First page or signature page from divorce/separation agreement listing names of both parties
  • Download the COBRA Rights Notice (signed by subscriber and spouse)
  • Download HIPPA Notice (no signature required)
  • Download the HSA form if you choose a High Deductible Plan

Documents

Required Documents for Employees Re-Enrolling without dependent changes

  • Download and complete Health Insurance Enrollment Form (SSN and DOB are mandatory and form signed and dated by subscriber)
  • Download the HSA form if you choose a High Deductible Plan

Documents