Group Application/Change Form

TEMPLE UNIVERSITY Human Resources

Personal Choice Health Insurance for Regular Adjunct Faculty Group Application Enrollment Form

Eligible regular adjunct faculty may enroll in the medical plan within 31 days of their appointment date.

Please complete the following information (PLEASE PRINT):

NAME: TUID:

ADDRESS:

HOME PHONE: WORK PHONE:

BIRTH DATE: SSN#:

GENDER: HIRE DATE:

Benefit Elections

PERSONAL CHOICE (PPO) PLAN C3-F3-02

REGULAR ADJUNCT FACULTY MEMBER ONLY

REGULAR ADJUNCT FACULTY MEMBER AND DEPENDENT(S)

If you elect to include coverage for your spouse, certified domestic partner and/or eligible dependent child(ren), you are required to provide copies of your marriage certificate, certified domestic partner form and birth certificate(s) for your dependent child(ren).

NAME GENDER DATE OF BIRTH SSN#

M SPOUSE/PARTNER F

M CHILD F

of 2 TEMPLE UNIVERSITY Human Resources

Personal Choice Health Insurance for Regular Adjunct Faculty Group Application Enrollment Form

Single coverage elected

Documentation is enclosed for dependents to be covered.

Documentation is NOT enclosed for dependent coverage and I understand that my dependents will NOT have coverage until documentation is provided to the Benefits office.

For the following dependents Documentation is NOT enclosed:

NAME DATE OF BIRTH

SPOUSE/PARTNER

The effective date of coverage will be the 1st of the month following receipt of this form and all required documentation for dependent coverage.

Forms should be returned to the following address:

Temple University Benefits Department 2450 W. Hunting Park Avenue, 1st Floor Philadelphia, PA 19129 215-926-2270 (PHONE) 215-926-2288 (FAX)

By signing below, I certify that I have read and understand the eligibility requirements for continued coverage and that I understand that this is a medical only plan and does not include prescription, dental or vision coverage.

Signature Date Signed