Get the free LGHIP Status Change Form LG02 - State Employees Insurance - lghip

Form LG02 Revised 10/15 FOR LIB USE ONLY Date: LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM 2016 STATUS CHANGE FORM Initials: SUBSCRIBER INFORMATION (Please print or type.) Name (First, Middle Initial,

How to fill out lghip status change form

How to fill out LGHIP status change form:

1. Download the LGHIP status change form from the official LGHIP website or request a copy from your employer.
2. Begin by providing your personal information, including your full name, address, date of birth, and contact information.
3. Indicate the reason for the status change by checking the appropriate box or providing a brief explanation in the designated space.
4. If you have a new dependent, include their information in the relevant section, such as their name, relationship to you, and date of birth.
5. If you have lost a dependent, provide their information as well, along with the reason for the loss (e.g., marriage, divorce, age limit).
6. If you are changing your marital status, indicate whether you are getting married, divorced, or legally separated, and provide any relevant details.
7. Next, indicate whether you or your dependent(s) have gained or lost coverage from another insurance plan. If applicable, provide information about the other plan and the effective dates.
8. Review the completed form to ensure all the information is accurate and complete.
9. Sign and date the form.
10. Submit the form to the appropriate entity, such as your employer's HR department or the LGHIP administrator.

Who needs LGHIP status change form:

1. Employees who have experienced a change in marital status, such as getting married, divorced, or legally separated.
2. Employees who have gained or lost dependents, such as having a child or no longer having a dependent.
3. Employees who have gained or lost coverage from another insurance plan.
4. Employees who have experienced any other change in their eligibility or coverage under the LGHIP.

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What is lghip status change form?

LGHIP status change form is used to report any changes in the status of an individual covered under the Legal Guardianship and Health Insurance Program.

Who is required to file lghip status change form?

The legal guardians or individuals responsible for the covered individual's health insurance are required to file the LGHIP status change form.

How to fill out lghip status change form?

To fill out the LGHIP status change form, you need to provide information about the covered individual, details of the status change, and sign the form as required.

What is the purpose of lghip status change form?

The purpose of the LGHIP status change form is to ensure that the program has up-to-date information about the covered individual's status for health insurance coverage.

What information must be reported on lghip status change form?

The LGHIP status change form requires information about the covered individual, the change in status, effective date of the change, and any supporting documentation.