18184

Employee No.: ________________________

Denver Health and Hospital Authority
2018 Employee Benefits Election/Change Form
Personal Information
Name: Lisa Perez Street: 7683 S Brentwood Ct Home Phone: (303) 868-4701
SSN: 525-85-6871 City, ZIP: Littleton, 80128 Work Phone:
Department Use ONLY. Entered by:
FTE: Date of Birth: 08-25-1988
Hours: 36 per week Hire Date: January 2013 BN31 PR39 HR13 Initial
Change Enrollment: Proof of all below events required
Add Dependents Due To: Involuntary loss of Coverage Remove Dependents Due To:

Marriage Birth/Adoption Divorce/Deceased Obtained Other Coverage

Dependent Information
To add dependent information you will need to provide the HR Employee Benefits Center with your Marriage Certificate to add
your spouse and/or Birth Certificate(s) to add your children.
Last Name, First Name, MI SSN Sex Relation Date of Birth Health Dental Vision
Spouse
Child
Perez, Raegan 718-33-8155 F 08/08/2018 x
Child
Child
Basic Coverage
DENVER HEALTH MEDICAL PLANS DELTA DENTAL OF COLORADO
Check the plan and coverage level you want to enroll in and Check the plan and coverage level you want to enroll in and
indicate which dependents are to be covered above. indicate which dependents are to be covered above.

SELECT PLAN SELECT COVERAGE LEVEL SELECT PLAN SELECT COVERAGE LEVEL
Denver Medical Care HMO Employee (EE)Only EPO3C Basic – GRP 7155 Employee (EE) Only
Highpoint HMO EE & Spouse (SP) EPO 1B – GRP 587 EE & Spouse (SP)
Highpoint POS EE & Child (ren) PPO/Premier – GRP 7967 EE & 1 Child
EE, SP & Child(ren) EE & 2 or more Children
*WAIVE Medical Coverage *WAIVE Dental Coverage EE, SP & Child (ren)
*If your FTE is greater than 0.7, you MUST provide proof of
other coverage in order to waive medical coverage. *Make sure that your dependent information above is complete
and indicate which dependents are to be covered above.
Supplemental Coverage

Voluntary Vision Flexible Spending accounts (FSAs)

If you wish to enroll in the vision plan, check the coverage If you wish to enroll in a FSA, check the type(s) of accounts you wish
option below and indicate which dependents are to be to enroll in, and complete the appropriate FSA enrollment form.
covered above.
Single 2-Party Family Health Care Dependent Care
Short-Term and Long-Term Disability
Short-Term and Long-Term Disability at 60% wage replacement is provided at no cost to all benefit eligible employees.
Short-Term Disability Long-Term Disability
60% Wage Replacement 60% Wage Replacement
YES, purchase 10% buy-up to 70% YES, purchase 10% buy-up to 70%
Other Voluntary Plans
If you wish to enroll in any of the following plans, indicate which plans you wish to participate in. You MUST complete the
enrollment or application forms for each of these plans. Underwriting may be required for participation. Critical Illness and
Universal Life/Long Term Care (LTC) enrollment is only allowed as a new hire or during open enrollment.
Critical Universal Life/Long-Term
Voluntary Life/AD&D Hyatt Legal Plan
Illness Care (LTC)
I authorize Denver Health to make payroll deductions for the above benefits that I have selected. I understand that no changes
can be made to these elections prior to Open Enrollment unless I experience a “Qualifying Event.”

Employee Signature: _______________________________________________________ Date: ____

10/15/2018 __