On the Group Enrollment Form...

Section 1

• Complete in full.
  

 Section 2

• Check the box that indicates the reason for your change.
  

• Complete the Date of Event box.
  

 Section 3

• Only list the dependents that will be affected by this change.
  

• If adding a dependent(s) to a TVHP (HMO) or VHP plan, you must indicate a Primary Care Physician, ID number and existing patient status.

• If the dependent(s) is 19 or older, complete the student section and indicate the name of the school and its location, the student's begin date and anticipated graduation date.
  

 Section 4

• If you or your dependent(s) are covered by another health or dental plan, complete this section.
  

 Section 7

• Subscriber's signature and date.