Copyright Forrest T. Jones & Company, Inc. Please obtain an Enrollment Application from each...
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Transcript of Copyright Forrest T. Jones & Company, Inc. Please obtain an Enrollment Application from each...
![Page 1: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/1.jpg)
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.
![Page 2: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/2.jpg)
Copyright Forrest T. Jones & Company, Inc.
Employee Application/Health Statement is available at www.ftj.com/meuhp
![Page 3: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/3.jpg)
Copyright Forrest T. Jones & Company, Inc.
Employee completes ONLY yellow questions. Prints the application and signs on first page
Returns to Payroll
![Page 4: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/4.jpg)
Copyright Forrest T. Jones & Company, Inc.
Information for Spouse and child ONLY IF they are to be covered under the new plan.
![Page 5: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/5.jpg)
Copyright Forrest T. Jones & Company, Inc.
If any box is marked yes, please make sure the information is added below.
Employee signs in blue area
![Page 6: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/6.jpg)
Copyright Forrest T. Jones & Company, Inc.
Please make sure Hours/Occupation and Date of Hire are completed
Employee should check who is to be covered under the new plan.
![Page 7: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/7.jpg)
Copyright Forrest T. Jones & Company, Inc.
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.
![Page 8: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/8.jpg)
Copyright Forrest T. Jones & Company, Inc.
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.
![Page 9: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/9.jpg)
Copyright Forrest T. Jones & Company, Inc.
Employee only needs to read – She does not need to sign this page.
![Page 10: 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.](https://reader030.fdocuments.in/reader030/viewer/2022032804/56649e585503460f94b50bf6/html5/thumbnails/10.jpg)
Copyright Forrest T. Jones & Company, Inc.
THANK YOU FOR ALL YOU DO!
Questions: Call 800-821-7303 ext 1179