generalinfo

MEDICAL SAVINGS ACCOUNTS/HEALTH SAVINGS ACCOUNTS
GENERAL INFORMATION
COMPLETE THIS SECTION FOR APPLICATION AND SPOUSE < IF APPLICABLE >

APPLICANT

LAWFUL SPOUSE

LAST NAME FIRST NAME INITIAL	LAST NAME FIRST NAME INITIAL
MAILING ADDRESS/ BOX No.	MAILING ADDRESS/ BOX No.
CITY, STATE, ZIP	CITY, STATE, ZIP
[ ] SINGLE [ ] MARRIED [ ] DIVORCED [ ] WIDOWED]	[ ] SINGLE [ ] MARRIED [ ] DIVORCED [ ] WIDOWED]
HOME PHONE WORK PHONE ( ) - ( ) -	HOME PHONE WORK PHONE ( ) - ( ) -
OCCUPATION HOURS PER WEEK	OCCUPATION HOURS PER WEEK
EMPLOYER'S NAME * LOCATION (CITY,STATE) * # OF EMPLOYEES	EMPLOYER'S NAME * LOCATION (CITY,STATE * # OF EMPLOYEES
NAME OF EMPLOYERS GROUP HEALTH INSURANCE COMPANY	NAME OF EMPLOYERS GROUP HEALTH INSURANCE COMPANY


FAMILY INFORMATION LIST THE FOLLOWING INFORMATION FOR ALL FAMILY MEMBERS APPLYING FOR COVERAGE

FAMILY MEMBERS FIRST NAME LAST NAME	SEX	RELATION TO APPLICANT*	BIRTHDAY Mo/Day/yr	SOCIAL SECURITY #	WEIGHT Lbs.	HEIGHT FT/IN	NAME OF CURRENT PHYSICIAN	P E C
APPLICANT	[ ] M [ ] F	APPLICANT	/ /	- -	.		.	.
SPOUSE	[ ] M [ ] F	.	/ /	- -	.		.	.
UNMARRIED CHILDREN (UNDER 26 - ELDEST FIRST)	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.
.	[ ] M [ ] F	.	/ /	- -	.		.	.

* e.g., child, stepchild, adopted child, child under legal guardianship, etc.

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