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Form LG02B Revised 8/19FOR LIB USE ONLYLOCAL GOVERNMENT HEALTH INSURANCE PROGRAM 2020 NEW DEPENDENT Format: Initials: SUBSCRIBER INFORMATION (Please print or type.) Name (First, Middle Initial, Last)Social

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How to fill out lghip new dependent form

01

Obtain the lghip new dependent form from the designated office or website.

02

Fill out the personal information of the dependent, including their full name, date of birth, Social Security number, and contact details.

03

Provide details of the relationship between the dependent and the lghip member, such as spouse, child, or domestic partner.

04

Indicate whether the dependent is currently covered by any other health insurance plan.

05

If the dependent is covered by another plan, provide information about the coverage and policy number.

06

Sign and date the form to certify the accuracy of the information provided.

07

Submit the completed form to the appropriate lghip office or online portal.

Who needs lghip new dependent form?

01

Any individual who requires to add a new dependent to their lghip insurance coverage needs to fill out the lghip new dependent form. This includes individuals who have recently married, had a child, or entered into a domestic partnership.

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What is lghip new dependent form?

The lghip new dependent form is a form used to add new dependents to the LGHIP (Local Government Health Insurance Plan) coverage.

Who is required to file lghip new dependent form?

Employees who wish to add new dependents to their LGHIP coverage are required to file the lghip new dependent form.

How to fill out lghip new dependent form?

To fill out the lghip new dependent form, employees must provide the necessary information about the new dependents, such as their names, dates of birth, and relationship to the employee.

What is the purpose of lghip new dependent form?

The purpose of the lghip new dependent form is to ensure that new dependents are properly added to the LGHIP coverage and receive the benefits they are entitled to.

What information must be reported on lghip new dependent form?

The lghip new dependent form requires information about the new dependents, including their names, dates of birth, and relationship to the employee.

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