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Enrollment Form

If applying during Annual Enrollment – The effective date of your coverage will be January 1, if this form is completed in full and signed by December 31.  To ensure you receive your new Medical and Prescription Drug cards by January 1, your completed form should be submitted by mid-November.  Your initial premium is due the 1st of the month, for the upcoming month’s coverage.  Your initial premium billing statement will be sent to you once your enrollment has been processed.

If applying when turning 65 – The effective date of your coverage will be the 1st of the month following the signature date on this form, but not prior to the month in which you turn 65. If your birthday is on the 1st of the month, your coverage can be effective on the 1st of the month prior to your 65th birthday.

If you use a P.O. Box as your mailing address and you are enrolling in the Medical/Prescription Drug Plan, we need to have your physical street address. Your P.O. Box number will be used as your mailing address. Please provide this information in the section noted on the last page of this enrollment form.