Insurance Enrollment Form for Plan Year 2024

Midyear enrollments – To be eligible for a midyear enrollment after your initial employment date (other than Option Period), you must have lost other qualified health coverage (some exceptions apply). You can enroll yourself and your dependents only in the specific coverage that you lost. You must make your elections and sign the Insurance Enrollment Form or Insurance Change Form within 30 days of the qualifying event (the date the loss occurred).

Supersede enrollment – You have 30 days following your employment date to make any additions or changes to the coverage you elected. To make changes, you must submit a new Insurance Enrollment Form with SUPERSEDE written across the top. This alerts EGID that no qualifying event is required because the change is being made within 30 days of your employment date. Any changes made to your original coverage are effective the first day of the month following the date you sign the superseding form.

Elections – You must elect health coverage to be eligible for dental or life coverage through EGID. You can exclude health coverage if you have other qualified health coverage. You may be asked to provide proof of that coverage. Failure to provide proof when requested will result in termination of all coverage.

TRICARE (military only) – You must currently have TRICARE coverage as a current or former military member and be younger than 65 to be eligible for the TRICARE Supplement Plan. Electing to purchase the TRICARE Supplement Plan means that TRICARE will be primarily responsible for your medical coverage and the supplement plan will be secondarily responsible for coverage. By your election, you submit to the eligibility rules of TRICARE and the TRICARE Supplement Plan. These rules may be different from the rules of eligibility created by the State of Oklahoma. Medicare may become the primary insurer upon attaining eligibility for Medicare. For more information on the TRICARE Supplement Plan, refer to oklahoma.gov/omes/services/employees-group-insurance-division/tricare-supplement.html.

Dependent children must be under 26 to be eligible for enrollment.

If you cover one eligible dependent, you must cover all your eligible dependents. You can elect not to cover dependents who do not reside with you, are married, are not financially dependent on you for support, have other qualified health coverage, or are eligible for Indian or military benefits. You may be asked to provide proof of other coverage. Failure to provide proof when requested will result in termination of your dependents’ coverages.

You can cover your children and exclude your spouse from health, dental and/or vision coverage. If you choose this option, your spouse must sign and date the Spouse Exclusion Certification section of this form.

You can cover your children and exclude your spouse from life coverage only if your spouse has other qualified life coverage. You may be asked to provide proof of that coverage. Failure to provide proof when requested will result in termination of all coverage.

Once publicly declared, a common-law relationship can be dissolved only by legal divorce. You must enroll in Basic Life to enroll in Supplemental Life and/or enroll your dependents in Dependent Life.

You must enroll in Basic Life to enroll in Supplemental Life and/or enroll your dependents in Dependent Life.

When you enroll, you will be sent a confirmation statement that lists your coverage, the effective date of your coverage and the premium amounts. It allows you to review your coverage so that any errors can be identified and corrected. Corrections should be submitted to your insurance coordinator or EGID within 60 days of the election. Corrections reported after 60 days will be effective the first of the month following notification.

Notification time limits – The deadline for submitting this form to EGID is strictly enforced. Forms not received within the specified time will not be processed.

• New hire enrollment: Your form must be received by EGID within 40 days of your initial employment date.
• Midyear election enrollment: Your form must be received by EGID within 40 days of the qualifying event.