Instructions for completing the Health Benefits Information Form.

Page 1

• PRIMARY MEMBER INFORMATION: Complete page 1 by filling in the requested information about yourself.  Please print clearly.
  

Page 2

• SBOA/NJ HEALTH BENEFITS ELIGIBILITY PROVISIONS:  This is a reference page to help you determine which “Group” you are eligible for.
  

Page 3

• COVERAGE ELECTIONS AND MONTHLY PREMIUM AMOUNTS:  Choose which coverage you wish to purchase.  There is single, two-person, and family coverage, different co-insurance levels, an option to purchase dental coverage if it is not included in the plan you have selected, and an option to purchase PHCS National Coverage (this means that you would have a national network of health care providers to choose from).  Add up all of your selections to find out how much your monthly premium will be.
  
  

• OTHER INSURANCE INFORMATION:  If you, your spouse or dependents are covered by any other insurance, complete this section of the enrollment form.
  
  

• SBOA/NJ LIFE INSURANCE BENEFICIARIES:  List beneficiary and relationship to you.  List a contingent beneficiary as a secondary beneficiary in case you are predeceased by your primary beneficiary.
  

Page 4

• DEPENDENT INFORMATION:  List spouse and/or other dependents in this section.  If additional space is needed, please use the back of this form, and supply the same information for each dependent.
  
  

• SIGNATURE:  Sign and date the enrollment form to validate it.
  
  

There is a 90-day waiting period from the day you enroll for the health insurance to take effect, and a 9-month waiting period for the dental coverage to begin (except during open enrollment in December).  Incomplete forms will be returned and the waiting period will not begin until all required information is received.  RETURN THE COMPLETED ENROLLMENT FORM TO SBOA/NJ BY MAIL OR IN PERSON.  WE ARE AVAILABLE TO ANSWER QUESTIONS MONDAY THROUGH FRIDAY FROM 8:30 AM TO 4:30 PM.