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 #
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
 [?]
 
  Please complete, sign and submit the Life Insurance Beneficiary Form to Postdoc Office, Director of the Office of Postdoctoral Affairs, School of Graduate Studies, Case Western Reserve University, Tomlinson Hall 215, 10900 Euclid Ave., Cleveland, Ohio 44106-7027
 
I agree and understand the Terms and Conditions.
Yes
No
 
I have read the General Notice of COBRA Continuation Rights.
Yes
No
 
I have read the Insurance Carrier Privacy Notice.
Yes
No
 
I have read the required notice of the Insurance Marketplace.
Yes
No
 
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 GPA site. Please print and keep a copy of the enrollment form for your records in the event eligibility verification is required.
Date: