TURNING POINT HEALTHPLAN CHANGE FORM NOTE: Please Print except for Signature THE LOOMIS COMPANY

Employee Name Social Security Number Coverage(s) Added

(Last First Middle Initial) - - LOOMIS COMPANY USE ONLY
PPO
Other
Marital Status Remarks:
Single
Married
Divorced
Widowed
Separated
Addition of Dependent Coverage
Spouse Effective Date / /
Effective Date Employee
Child(ren) Natural Adopted Stepchild / /
Effective Date: / / Effective Date Dependent
Reason: / /
Terminate ALL Dependent Coverage Class:
Effective Date: / / Dependents Eligible for Coverage
Processed Date:
None / /
Spouse User ID:
Child(ren) (No.)
Other Dependent
Relationship

Termination of Dependents Spouse Child(ren)

Names:
Reason:
Effective Date: / /
Change: From To Occupation:
Network
Location
Plan
Other
Reinstate Insurance Prior Effective Date of Temination
Effective Date: / /
Cancel ALL Coverage EMPLOYERS USE ONLY
Termination of Employment Leave/Lay Off Group # 5752 Name of Employer: L. Robert Kimball and Associates
Re-enrollment Other Coverage

Effective Date: / /
Other Changes: Enrollment Enrollment Status Initials
Name: Full Time
Account No. Effective Date
Address Part Time
COBRA (Attach Election From)
City State Zip Country
Retiree
Location Hourly Salaried
Effective Date / /
Wages
Class
$ Per Hour Week Month Year
Creditable Coverage Yes No
Pre-Existing Applies Yes No Number of Months:

X
Employee Signature Date
USE THIS SPACE TO LIST ALL ELIGIBLE DEPENDENTS. LAST NAME REQUIRED IF DIFFERENT FROM EMPLOYEE’S. IF ADDITIONAL SPACE IS NEEDED PLEASE ATTACH SHEET.
Spouse’s Name (Last First MI) Date of Birth (MM/DD/YY) Sex Social Security Number
/ / M F - -
Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student
/ / M F - - Son Daughter Other Yes No
Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student
/ / M F - - Son Daughter Other Yes No
Dependent’s Name Date of Birth (MM/DD/YY) Sex Social Security Number Relationship Full Time Student
/ / M F - - Son Daughter Other Yes No