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Cortland County GROUP BENEFIT PLAN ENROLLMENT FORM PLEASE PRINT ALL INFORMATION MANAGEMENT NURSES GENERAL CSEA ROAD DOERC CORR/CIVILIAN LAST NAME: FIRST NAME: SEX: MALE FEMALE MARITAL STATUS: SINGLE MARRIED DIVORCED LEGALLY SEPARATED SS DATE OF BIRTH DATE OF HIRE EFFECTIVE DATE ACTIVE (PART-TIME) ACTIVE (FULL-TIME) COBRA RETIRED WITH OUT MEDICARE RETIRED WITH MEDICARE MEDICARE CLAIM NO. PART A EFF. DATE: PART B EFF. DATE: ADDRESS: STREET CITY, STATE, ZIP COUNTY HOME PHONE EMAIL ADDRESS INDIVIDUAL FAMILY MEDICAL (INCLUDES PRESCRIPTION) DENTAL VISION Spouse Name (First, Last) Sex Date of Birth Social Security # Children Name (First, Last) Relationship Sex Date of Birth Social Security # College Name Disabled Y/N? Spouse Information (Only complete if enrolling spouse) Medicare Eligible? Yes No Medicare Claim No. Is spouse employed? Yes No Enrolled in Group Health Plan? Yes No Part A Eff. Date: Type of Coverage: Medical Dental Prescription Vision Part B Eff. Date: Single Family Name, Address, and Phone # of Spouse's Employer: Name, Address, and Policy Number of Other Health Insurance Coverage: I AUTHORIZE PAYMENT OF BENEFITS TO ANY DOCTOR, PHYSICIAN OR OTHER PROVIDER FOR SERVICES WHICH HE/SHE MAY RENDER TO ME OR MY FAMILY. I CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I DESIRE TO PARTICIPATE IN THE GROUP MEDICAL PROGRAM. DATE SIGNATURE OF EMPLOYEE