- 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.
- 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.
- If you or your dependent(s) are covered by another health or dental plan, complete this section.
- Subscriber's signature and date.