• Health Benefits: Forms

     

    Along with the forms below, additional paperwork may be required:

    IF EMPLOYEE IS:

    OPTING-OUT: A copy of the certificate of marriage, civil union license or nj certificate of domestic partnership
    or birth certificate for family reimbursement

    ADDING A SPOUSE/PARTNER: A copy of the certificate of marriage, civil union license or nj certificate of domestic partnership
    or letter from prior insurance coverage showing termination date

    REMOVING A SPOUSE/PARTNER: A copy of the divorce/dissolution decree

    ADDING CHILDREN/DEPENDENTS: A copy of the birth certificate/adoption papers & social security card and or letter from prior insurance coverage showing termination date

    IMPORTANT INFORMATION
     All forms must be received within 30 days of life event. Horizon will not accept applications after 31 days.
    Newborns are automatically covered for 30 days after birth. Please do not wait beyond the 30 days to send in the forms, even without the birth certificate or SS card. I can enroll them pending receipt of these documents

    ENROLLMENT/CHANGE FORMS
     
    OPT-OUT FORMS
    • Health Benefits Opt-Out Waiver
      (To opt-out of ALL insurances)
      (If currently enrolled in an insurance plan, please complete the 3 change forms above as well)
     
    CLAIM FORMS