Copyright Forrest T. Jones & Company, Inc. Please obtain an Enrollment Application from each employee and retiree who is now covered or wants to be covered.

Copyright Forrest T. Jones & Company, Inc.

Please obtain an Enrollment Application from each employee

and retiree who is now covered

or wants to be coveredby the District’s health plan.


Employee Application/Health Statement is available at www.ftj.com/meuhp


Employee completes ONLY yellow questions. Prints the application and signs on first page

Returns to Payroll


Information for Spouse and child ONLY IF they are to be covered under the new plan.


If any box is marked yes, please make sure the information is added below.

Employee signs in blue area


Please make sure Hours/Occupation and Date of Hire are completed

Employee should check who is to be covered under the new plan.


Only complete if EMPLOYEE is waiving coverage.

Example 1: Bob (employee) is covered under his wife’s plan and will not be on the District plan. Bob should complete the waiver information.

Example 2: Jane (employee) will be covered on District Plan. Jane’s husband and kids have other coverage. Jane should not complete the waiver information.


Prior Health Insurance InformationComplete with CURRENT CARRIER information. Leave Cancel Date blank.

Other Health Insurance Information – Complete only for those family members who will be covered by the District plan AND other health insurance and / or Medicare.


Employee only needs to read – She does not need to sign this page.


THANK YOU FOR ALL YOU DO!

Questions: Call 800-821-7303 ext 1179

Copyright Forrest T. Jones & Company, Inc. Please obtain an Enrollment Application from each employee and retiree who is now covered or wants to be covered.

Documents

employee signs

jane employee

bob employee

district plan

new plan

waiver information

districts health plan

wifes plan