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Complete all applicable sections. Group Policy No. Subgroup/Class No HIP Active Retiree COBRA PPO Active G0020720 AFSCME P001-1101 P004-7101 P005-9101 P002-1102 IAFF P006-1201 P004-7202 P005-9202 Non-Rep P006-1302 SEIU/OPEU SPA Section 1 Enrollment Information Employer/Group Name Date of Full Time Hire required month Effective Date day Number of Hours Worked Per Week year a Employment Status Active Other Section 2 Employee Information Employee Last Name First Name Mailing Address City Home...
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