Health Insurance Application/Change Form

Department of Employee Trust Funds
Health Insurance Application/Change Form
Please complete the requested information and return to your employer (or ETF for Retirees/Continuants)
as soon as possible. Only complete if you are the employee/retiree/continuant applying for coverage.
Read the Terms and Conditions accompanying this application prior to signing and submitting to your
employer (or ETF for Retirees/Continuants).
HDHP is a High Deductible Health Plan as explained in the Information pages under Section 4.
For detailed information regarding eligibility requirements, please read the informational pages attached.
For information on required documentation (
), please see the included chart “Documentation
Requirements” on Page 10.
Contact your employer (or ETF for Retirees/Continuants) with any questions not answered here.
*Indicates required field IYC = Annual It’s Your Choice
1. APPLICANT INFORMATION
Please print
ETF Member ID* SSN*
First name* M.I. Last name* Previous name
Home mailing address*—street and No. City* State* ZIP code* Check here if
updating address,
name, phone, e-mail
or marital status.
Primary phone No.*
( )
Country (if not USA) Applicant e-mail
Birth date* Gender*
M
F
Physician/Clinic*
Marital or domestic partnership (DP) status* Single Married DP Divorced Widowed
Event Date* ________________________(not required for single)
2.SPOUSE/DOMESTIC PARTNER (DP) INFORMATION
Check here if only updating spouse/DP information
SSN*
Name* (First, M.I., Last) Previous name Birth date*
Physician/Clinic* Tax dependent Yes
No
Gender* M
F
3.DEPENDENT INFORMATION: (Excludes spouse/DP) Add Coverage, Add Dependent, Remove Dependent
Check here if only updating dependent information
Social
Security
number*
First
name*
M.I.
Last name*
Birth date*
Gender*
Rel. code*
Tax dep?
Disabled?
Enter Clinic/Physician*
or Provide Dependent
Address for COBRA, if
removing (may attach
separate sheet).
ET-2301 (Rev. 11/3/14) Page 1
Page 1/10
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Health Insurance Application/Change Form PDF

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