Turning Point Change Form
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TURNING POINT HEALTHPLAN CHANGE FORM Employee Name (Last
First
Middle Initial)
THE LOOMIS COMPANY
NOTE: Please Print except for Signature Social Security Number Coverage(s) Added PPO
LOOMIS COMPANY USE ONLY
Other Marital Status
Remarks:
Single Married Divorced Widowed Separated Addition of Dependent Coverage Spouse
Effective Date
Child(ren) Effective Date: Reason:
Natural /
/ Adopted /
Terminate ALL Dependent Coverage Effective Date: /
/ Effective Date Employee / / Effective Date Dependent / /
Stepchild
Class: /
Dependents Eligible for Coverage None Spouse Child(ren) (No.) Other Dependent Relationship
Termination of Dependents
Spouse
Child(ren)
Names: Reason: Effective Date: Change:
/ From
/ To
Network Location Plan Other Reinstate Insurance Effective Date: /
Prior Effective Date of Temination /
Occupation:
Processed Date: / User ID:
/
Cancel ALL Coverage Termination of Employment Re-enrollment Effective Date: Other Changes:
Leave/Lay Off Other Coverage /
EMPLOYERS USE ONLY Group # 5752
Name of Employer: L. Robert Kimball and Associates
/ Enrollment
Name:
Account No.
Address City
State
Zip
Effective Date
/
/
Initials
Enrollment Status Full Time
Effective Date
Part Time COBRA (Attach Election From)
Country
Retiree Location
Hourly Wages $ Yes Yes
Class Creditable Coverage Pre-Existing Applies
Salaried Per No No
Hour
Week
Month
Year
Number of Months:
X Employee Signature
Date
USE THIS SPACE TO LIST ALL ELIGIBLE DEPENDENTS. LAST NAME REQUIRED IF DIFFERENT FROM EMPLOYEE’S. IF ADDITIONAL SPACE IS NEEDED PLEASE ATTACH SHEET. Spouse’s Name (Last First MI) Date of Birth (MM/DD/YY) Sex Social Security Number / / M F Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No
First
Middle Initial)
THE LOOMIS COMPANY
NOTE: Please Print except for Signature Social Security Number Coverage(s) Added PPO
LOOMIS COMPANY USE ONLY
Other Marital Status
Remarks:
Single Married Divorced Widowed Separated Addition of Dependent Coverage Spouse
Effective Date
Child(ren) Effective Date: Reason:
Natural /
/ Adopted /
Terminate ALL Dependent Coverage Effective Date: /
/ Effective Date Employee / / Effective Date Dependent / /
Stepchild
Class: /
Dependents Eligible for Coverage None Spouse Child(ren) (No.) Other Dependent Relationship
Termination of Dependents
Spouse
Child(ren)
Names: Reason: Effective Date: Change:
/ From
/ To
Network Location Plan Other Reinstate Insurance Effective Date: /
Prior Effective Date of Temination /
Occupation:
Processed Date: / User ID:
/
Cancel ALL Coverage Termination of Employment Re-enrollment Effective Date: Other Changes:
Leave/Lay Off Other Coverage /
EMPLOYERS USE ONLY Group # 5752
Name of Employer: L. Robert Kimball and Associates
/ Enrollment
Name:
Account No.
Address City
State
Zip
Effective Date
/
/
Initials
Enrollment Status Full Time
Effective Date
Part Time COBRA (Attach Election From)
Country
Retiree Location
Hourly Wages $ Yes Yes
Class Creditable Coverage Pre-Existing Applies
Salaried Per No No
Hour
Week
Month
Year
Number of Months:
X Employee Signature
Date
USE THIS SPACE TO LIST ALL ELIGIBLE DEPENDENTS. LAST NAME REQUIRED IF DIFFERENT FROM EMPLOYEE’S. IF ADDITIONAL SPACE IS NEEDED PLEASE ATTACH SHEET. Spouse’s Name (Last First MI) Date of Birth (MM/DD/YY) Sex Social Security Number / / M F Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student / / M F Son Daughter Other Yes No
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