On the Group Enrollment Form...

Section 1

• Complete entire section.
  

 Section 2

• Check the box that indicates the reason for enrolling.
• Complete the Date of Event box, which will correspond with the Date of Hire in section 1.
  

 Section 3

• List all dependents to be covered by your health care coverage, including yourself.
  
• If applying for TVHP (HMO) or VHP you must indicate a Primary Care Physician, ID number and existing patient status for each dependent.
• 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.