copyright forrest t. jones & company, inc. please obtain an enrollment application from each...
TRANSCRIPT
Copyright Forrest T. Jones & Company, Inc.
Please obtain an Enrollment Application from each employee
and retiree who is now covered
or wants to be coveredby the District’s health plan.
Copyright Forrest T. Jones & Company, Inc.
Employee Application/Health Statement is available at www.ftj.com/meuhp
Copyright Forrest T. Jones & Company, Inc.
Employee completes ONLY yellow questions. Prints the application and signs on first page
Returns to Payroll
Copyright Forrest T. Jones & Company, Inc.
Information for Spouse and child ONLY IF they are to be covered under the new plan.
Copyright Forrest T. Jones & Company, Inc.
If any box is marked yes, please make sure the information is added below.
Employee signs in blue area
Copyright Forrest T. Jones & Company, Inc.
Please make sure Hours/Occupation and Date of Hire are completed
Employee should check who is to be covered under the new plan.
Copyright Forrest T. Jones & Company, Inc.
Only complete if EMPLOYEE is waiving coverage.
Example 1: Bob (employee) is covered under his wife’s plan and will not be on the District plan. Bob should complete the waiver information.
Example 2: Jane (employee) will be covered on District Plan. Jane’s husband and kids have other coverage. Jane should not complete the waiver information.
Copyright Forrest T. Jones & Company, Inc.
Prior Health Insurance InformationComplete with CURRENT CARRIER information. Leave Cancel Date blank.
Other Health Insurance Information – Complete only for those family members who will be covered by the District plan AND other health insurance and / or Medicare.
Copyright Forrest T. Jones & Company, Inc.
Employee only needs to read – She does not need to sign this page.
Copyright Forrest T. Jones & Company, Inc.
THANK YOU FOR ALL YOU DO!
Questions: Call 800-821-7303 ext 1179