<p> TEMPLE UNIVERSITY Human Resources</p><p>Personal Choice Health Insurance for Regular Adjunct Faculty Group Application Enrollment Form</p><p>Eligible regular adjunct faculty may enroll in the medical plan within 31 days of their appointment date.</p><p>Please complete the following information (PLEASE PRINT):</p><p>NAME: TUID: </p><p>ADDRESS: </p><p>HOME PHONE: WORK PHONE: </p><p>BIRTH DATE: SSN#: </p><p>GENDER: HIRE DATE: </p><p>Benefit Elections</p><p>PERSONAL CHOICE (PPO) PLAN C3-F3-02</p><p>REGULAR ADJUNCT FACULTY MEMBER ONLY</p><p>REGULAR ADJUNCT FACULTY MEMBER AND DEPENDENT(S)</p><p>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).</p><p>NAME GENDER DATE OF BIRTH SSN#</p><p>M SPOUSE/PARTNER F</p><p>M CHILD F</p><p>M CHILD F</p><p>M CHILD F</p><p>M CHILD F</p><p>PAGE 1 of 2 TEMPLE UNIVERSITY Human Resources</p><p>Personal Choice Health Insurance for Regular Adjunct Faculty Group Application Enrollment Form</p><p>Single coverage elected</p><p>Documentation is enclosed for dependents to be covered.</p><p>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.</p><p>For the following dependents Documentation is NOT enclosed:</p><p>NAME DATE OF BIRTH</p><p>SPOUSE/PARTNER </p><p>CHILD </p><p>CHILD </p><p>CHILD </p><p>CHILD </p><p>The effective date of coverage will be the 1st of the month following receipt of this form and all required documentation for dependent coverage.</p><p>Forms should be returned to the following address:</p><p>Temple University Benefits Department 2450 W. Hunting Park Avenue, 1st Floor Philadelphia, PA 19129 215-926-2270 (PHONE) 215-926-2288 (FAX)</p><p>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.</p><p>Signature Date Signed</p><p>PAGE 2 of 2</p>