Medical Enrollment Form for Active Employees
This document is the Medical Enrollment Form for active employees of Ball State University. It includes sections for employee information, coverage levels, dependent information, and authorization. Please ensure all required fields are filled out and submit to Payroll and Employee Benefits.
Edit, Download, and Sign the Medical Enrollment Form for Active Employees
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, you will need to provide detailed information about yourself and your dependents. Make sure to select the appropriate coverage level and include any supporting documentation. Once completed, sign and submit the form as instructed.
How to fill out the Medical Enrollment Form for Active Employees?
1
Enter your personal information in Section 1.
2
Select your coverage level in Section 2.
3
Provide details about any dependents in Section 4.
4
Complete the authorization in Section 5.
5
Submit the form to Payroll and Employee Benefits.
Who needs the Medical Enrollment Form for Active Employees?
1
New employees who need to enroll in the medical plan.
2
Current employees participating in annual open enrollment.
3
Employees experiencing a qualifying event like marriage or birth.
4
Employees adding dependents to their coverage.
5
Employees who need to make changes due to status/event changes.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Medical Enrollment Form for Active Employees along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Medical Enrollment Form for Active Employees online.
You can edit this PDF on PrintFriendly using our intuitive PDF editor. Upload the document and make any necessary changes directly within the form. Once you are satisfied with your edits, save and download the updated PDF.
Add your legally-binding signature.
You can sign the PDF on PrintFriendly using our built-in signature tool. Simply open the document in our editor, click on the signature field, and draw or upload your signature. Save the signed document for your records.
Share your form instantly.
You can share the PDF on PrintFriendly by using our sharing options. After editing and signing the document, click on the share button and choose your preferred method. You can share via email, link, or directly to social media.
How do I edit the Medical Enrollment Form for Active Employees online?
You can edit this PDF on PrintFriendly using our intuitive PDF editor. Upload the document and make any necessary changes directly within the form. Once you are satisfied with your edits, save and download the updated PDF.
1
Upload the PDF document to PrintFriendly.
2
Open the document in our PDF editor.
3
Make the necessary edits directly within the form.
4
Save your changes.
5
Download the updated PDF.
What are the instructions for submitting this form?
Submit the completed Medical Enrollment Form to Payroll and Employee Benefits at ADG29. You can also email the form to benefits@bsu.edu or fax it to (765) 285-8795. Ensure all required fields are filled out and any necessary supporting documentation is included. For any questions or assistance, contact the Payroll and Employee Benefits office at (765) 285-8461. Ensure you submit the form within the designated deadlines or 31 days of experiencing a qualifying event.
What are the important dates for this form in 2024 and 2025?
Ensure to submit your Medical Enrollment Form during the annual open enrollment period or within 31 days of a qualifying event in 2024 and 2025.
What is the purpose of this form?
The purpose of this medical enrollment form is to provide active employees at Ball State University with a means to enroll in the university's medical plan. The form collects essential information required for the enrollment process, including employee details, coverage levels, and dependent information. By completing and submitting this form, employees can ensure they and their dependents have access to the necessary medical coverage provided by Anthem BlueCross BlueShield.
Tell me about this form and its components and fields line-by-line.
- 1. Employee information: Includes personal details such as name, social security number, date of birth, address, and contact information.
- 2. Coverage level: Allows the employee to select their coverage level and specify the type of coverage plan.
- 3. Dependent information: Collects details about dependents including their name, address, social security number, and relationship to the employee.
- 4. Authorization: Requires the employee's signature and date to authorize the enrollment and any changes made.
What happens if I fail to submit this form?
Failure to submit this form can result in a lack of medical coverage for the employee and their dependents.
- No Coverage: Without submitting the form, the employee will not be enrolled in the medical plan.
- Missed Deadlines: Missing the submission deadlines can lead to delays in coverage or inability to enroll for the period.
How do I know when to use this form?
- 1. New Enrollment: For new employees enrolling in the medical plan for the first time.
- 2. Open Enrollment: During the designated open enrollment period for current employees.
- 3. Qualifying Event: When an employee experiences a life event such as marriage, birth, or loss of other coverage.
Frequently Asked Question
Can I edit the PDF on PrintFriendly?
Yes, you can easily edit the PDF using PrintFriendly's PDF editor.
How do I sign the PDF?
You can sign the PDF using the built-in signature tool in PrintFriendly's editor.
Can I share the edited PDF?
Yes, you can share the edited PDF via email, link, or social media using PrintFriendly's sharing options.
What information do I need to provide in the form?
You need to provide your personal information, coverage level, dependent details, and authorization.
How do I submit the completed form?
Submit the completed form to Payroll and Employee Benefits as instructed on the form.
Can I download the edited PDF?
Yes, you can download the edited PDF after making changes on PrintFriendly.
What if I have a qualifying event?
If you have a qualifying event, update the form with the necessary changes within 31 days of the event.
Can I add dependents to my coverage?
Yes, you can add dependents to your coverage by providing their details in Section 4.
Is my spouse eligible for coverage?
Your spouse is eligible for coverage if they meet the working spouse provision criteria outlined in the form.
Do I need to provide Social Security numbers?
Yes, Social Security numbers are required for all covered dependents as per federal law.
