Case Western Reserve University Postdoctoral Benefits Program
Enrollment, Change, Cancellation or Waiver Form

  Fields marked with are required to submit this form.
  1. Personal Information
First Name
Last Name
MI
Gender
Date of Birth
mm/dd/yyyy
/ /
Social Security # (or CWRU ID number)
Home Phone
Home Address (Number, Street, City, State, Zip)
Postdoc Email Address
Title
Marital Status
Effective Date of Coverage
mm/dd/yyyy
  2. Department Information
Department Contact Name
Dept. Contact Phone
Department Contact Email
Department Name
Appt./Flshp. Start Date
mm/dd/yyyy
Billing Contact Name
Billing Contact Phone
Billing Contact Email
Billing Contact Fax
Bill Me (Postdoc) Directly
Yes  No
  3.Type of Action or Qualifying Event (Check all that apply) Write in date of event, if applicable.
Section does not apply to Open Enrollment Changes
New Hire  [?]    Date: Domestic Partner Coverage: Please note: You must complete required Domestic Partnership Documentation in order to start coverage. Please refer to Section 9, Terms and Conditions for access to these documents. Delete family member - Specify family
    member in Sec 5

Date:

Select Reason:


If other, please specify:
Rehire    Date:
Change in appointment status Date: Change personal data for eligible family member

Date:
Add eligible family member
Date:
  3a. Opt-Out of Coverage (Waiver)   I understand if I opt out of the University - sponsored coverage, the University will not provide me or my family with medical, dental, vision, or life coverage.
Section does not apply to Open Enrollment Changes
I wish to decline all coverage:
I understand that if I decline coverage, I am declining coverage for all plans offered by the Case Western Reserve University Postdoctoral Benefits Program (medical, dental, vision, life) for myself and/or eligible dependents.		 I am declining coverage for the following dependents:

Spouse/DP

Child(ren)		 I am declining this coverage because (check one):

Covered by another plan

Other (please specify)
  4a. By checking YES, you and any eligible family member you add in Section 5 will be enrolled in all of the following plans:
   YES
Medical: Aetna Health Network Only (HNO) Dental: MetLife PPO Plan Vision: EyeMed Vision Plan Life: Standard Life and AD&D Insurance
  4b. By checking YES, you and any eligible family member you add in Section 5 will be enrolled in all of the following plans:
   YES
Medical: Aetna Open Access Managed Choice Point of Service (OAMC POS) Dental: MetLife PPO Plan Vision: EyeMed Vision Plan Life: Standard Life and AD&D Insurance
  5. Eligible Family Members to be covered - List individuals whom you are enrolling or deleting from coverage.
Check Action Desired
Enroll
Delete
  
Last Name
MI
First Name
Birthdate
Gender
Social Security #
(Optional) Name of Primary Care Physician - HNO only
Currently Disabled
Self
SAME AS ABOVE
Spouse/
DP
Child
 [?]
Child
 [?]
Child
 [?]
Child
 [?]
Child
 [?]
 
  6. Beneficiary Information:
Standard Life Insurance Company
Subject to the terms of the Group Contract(s), between Standard Life Insurance Company and said policyholder, I request that the following beneficiary (beneficiaries) be substituted under said contract(s) as my designated beneficiary (beneficiaries), in lieu of any and all beneficiaries previously named by me:
Primary Beneficiary Designation

Name of Beneficiary
(First, MI, Last Name)

Related To Me As:

Date of Birth
(yyyymmdd)

Address of Beneficiary
(Address, City, State, Zip)

Percentage
%
%
%
     
Percentage Total:
100%
Contingent Secondary Beneficiary Designation

Name of Beneficiary
(First, MI, Last Name)

Related To Me As:

Date of Birth
(yyyymmdd)

Address of Beneficiary
(Address, City, State, Zip)

Percentage
%
%
%
     
Percentage Total:
100%
*If more than one named, the beneficiaries shall share equally unless otherwise stated above.
Unless otherwise above expressly provided, if any beneficiary listed above designated predeceases me, the share which such beneficiary would have received if such beneficiary had survived me shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survived me, but if no designated beneficiary survives me, the beneficiary shall be determined as prescribed in said Group Contract(s).
This Designation of Beneficiary refers only to a Group Life Insurance contract.
This Designation of Beneficiary is subject to change as provided in said Group Contract(s).
TERMS AND CONDITIONS
By submitting this form, you agree to the following terms and conditions:
1. I understand that the health benefit plans that I have selected provide reimbursement for certain medical/dental/vision costs which are more fully described in the current Evidence of Coverage or Summary Plan Description. I understand there may be instances where treatment decisions made by my physician or service provider, or medical/dental/vision expenses I have incurred may not be covered by my health benefit plan.
2. I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may be subject to treatment as a late enrollee and may apply at next open enrollment. I further understand that if I decline enrollment for myself or my eligible dependents, because of other health coverage, I may in the future be able to enroll myself and/or my dependents in this plan provided I request enrollment within 30 days after such coverage ends. In addition, if a new relationship forms as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll myself and my dependent provided that I request enrollment within 30 days after such marriage, birth, adoption or placement for adoption.
3. Most of the Case Western Reserve University plans offered require resolution of malpractice and other disputes through binding arbitration. By enrolling in these plans you agree that any dispute between you (and/or your enrolled dependents) and the medical and/or dental plan must be submitted to binding arbitration if so required by the plan. You are giving up your right to a jury or court trial. For more information regarding each plan's arbitration provisions, please see the appropriate plan booklet.
4. You understand and accept all terms and conditions of the Case Western Reserve University Postdoctoral Benefits Program (Case-PBP) sponsored plans in which you are enrolled as stated in each plan's booklet.
5. When enrolling family members (eligible dependents), the carriers and/or Gallagher Benefit Services may require proof of eligiblity as marriage or birth certificates, adoption papers, tax records, student enrollment documentation (for full-time student eligibility) and you agree to provide such documentation upon request.
6. When you request either Case Western Reserve University or Gallagher Benefit Services (GPA) to intercede on your behalf regarding any issue, you authorize the plan to release to the University and/or GPA representatives any records needed to assist resolution. Some plans may require you to sign a release which allows the plan to release personal health information to the University and/or GPA representatives.
7. You authorize deductions from your earnings to cover your monthly costs, if any, for the plans you have chosen for yourself and your eligible dependents.
8. By submitting this form, you certify that all information provided is true to the best of your knowledge.
9. Domestic Partner Coverage: If you are enrolling your Domestic Partner in the Case-PBP, you must complete and submit required Domestic Partnership Documentation. Failure to do so could prevent your, and your Domestic Partner's, access to benefits under the plans offered. Please submit to the Postdoc Office, Office of Postdoctoral Affairs at the same address listed below for the Life Insurance Beneficiary Form.
10. Federal Privacy Notification: Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security Number is mandatory. Disclosure of the Social Security number is required pursuant to sections 6011 and 6051 of Subtitle F of the Internal Revenue Code and with Regulation 4, Section 404, 1256, Code of Federal Regulations under Section 218, Title II of the Social Security Act, as amended. The Social Security Number is used to verify your identity. The principal use of the number for purposes of the Case-PBP shall be to use as an identifier for the insurance carriers and benefit providers to verify your eligibility and to maintain claim records for you and your eligible dependents.
11. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA): COBRA provides for continuation of plan coverage for certain periods of time at monthly rates if you or your eligible dependents lose group medical, dental or vision coverage because you terminate your relationship with the University, die, divorce, legally separate or a child ceases to be eligible. Please read and review the "General Notice of COBRA Continuation Coverage Rights" in order to submit your enrollment form.
12. Certificate of Coverage, Evidence of Coverage and/or Summary Plan Descriptions and other documents, notices and communications regarding your health benefit plans may be transmitted electronically.
 
I have read the Gallagher Benefit Services Notice of Privacy Policy and Insurance Practices
Yes
No
  When you click "Submit and Create Printable Enrollment Form" below to submit your completed enrollment form, you are providing your electronic signature and you will be submitting your enrollment form to the secure Gallagher site. Please print and keep a copy of the enrollment form for your records in the event eligibility verification is required.
Date: