Part 1 – Identifying Information
1. Name (Last, First, Middle Initial)
2. Sex (M/F)
3. Date of Birth (mm/dd/yyyy)
4. SSN
5. Home Address (Including Zip Code)
6. Check one:
Active Employee
Retiree
Surviving Spouse
COBRA
7. Home Phone
8. Work Phone
Part 2 – Health Coverage
1. Check one:
New Enrollment (Basic Life Insurance
Form Mandatory)
Change Enrollment (Add/Remove Dep)
Decline/Waive Coverage
Terminate/Cancel Existing Coverage
Annual Enrollment
2. Select one of the health plans below
BCBS HMO (Network Blue New England)
BCBS PPO (Blue Care Elect Preferred)
Mass General Brigham Health Value HMO
4. Select coverage level
Individual
Family
3. PCP (Primary Care Physician)
5. Effective Date
Part 3 – Spouse/Dependent Information (to be completed if enrolling in Family Coverage)
List below all family members, including your spouse or former spouse (if eligible), who will be covered under your health plan. Attach a separate sheet
if additional space is required. Please provide all Social Security Numbers (required under Federal Law Section 111) and exact dates of birth for each
dependent. Important: The City of Boston requires you to provide a copy of eligibility documents such as a marriage certificate, legal separation
agreement, divorce decree, birth certificate, certificate of appointment as legal guardian, etc., for each covered spouse/dependent.
Add/Remove
+ / -
Last Name
First Name
Relationship
Date of Birth
(mm/dd/yyyy)
Sex
(M/F)
SSN (required)
PCP
Spouse Information – Only complete if covering a spouse
Is your spouse enrolled in Medicare? Yes No If yes, Medicare Claim Number:
Former Spouse Information – Only complete if covering a former spouse
Date of Divorce:
Former Spouse Home Address:
City: State: Zip:
Is your former spouse remarried? Yes No If yes, date of remarriage:
Are you remarried? Yes No If yes, date of remarriage:
Is your former spouse enrolled in Medicare? Yes No If yes, Medicare Claim Number:
Part 4 – Signature Required
Deduction Authorization: I authorize my employer, or direct my pension authority, to deduct from my payroll or pension check the amount
required for the coverage I have selected.
Health Insurance: I understand that once I choose a health plan, I cannot change plans until the next annual enrollment, even if my doctor or
hospital leaves the plan.
Survivors: I am a surviving spouse and certify that I have not remarried and understand that if I do remarry I am no longer eligible for City of
Boston coverage.
Retirees must collect a pension from Boston retirement system to be eligible for City of Boston coverage.
Signature of Applicant Date Signature of Authorized Official Date
City of Boston
Non-Medicare Health Insurance Enrollment Form
Employee ID: _____________
Return completed form to
Health Benefits & Insurance Division
Boston City Hall, Room 807
Boston, MA 02201
Fax: 617-635-3932
Eligibility: Employees working a minimum of 20 hours per week. The City of Boston requires eligible employees to enroll in
Basic Life coverage in order to enroll in health insurance coverage. See Basic Life coverage levels below.
Class 1 Active and retired employees $5,000
Class 2 Eligible Union Active Employees $5,000 or $10,000 (AFSCME (City Wide), Boston Typographical Union Local 13, Boston
Newspaper Printing Pressman’s Association, IBEW Local 103, Graphic Arts, Local 600, National Conference of Firemen &
Oilers, OPEIU, SENA Local 9158, AFSCME Local 1526)
Class 2 Reduces to $5,000 at retirement or employee no longer eligible for class
Part 1 – Identifying Information
1. Name (Last, First, Middle Initial)
2. Sex (M/F)
3. Date of Birth (mm/dd/yyyy)
4. SSN
5. Home Address (Including Zip Code)
6. Check one:
Active Employee
Retiree
7. Home Phone
8. Work Phone
Part 2 – Basic Life Insurance
1. Check one:
New Enrollment
Change/Update Beneficiary
Cancel Policy
2. Select one of the coverage levels below
$5,000 (Active & Retired Employees)
$10,000 (Only available for certain Unions)
3. Effective Date
Part 3 – Beneficiary Information
Primary Beneficiary: Designate at least one primary beneficiary for your policy. It is important to provide the correct home address and phone
number. If you designate more than one beneficiary, please be sure the total percentages of benefit equals 100%. If you do not designate a
percentage payable for each beneficiary, the total proceeds payable will be divided equally among each beneficiary. Attach a separate sheet if
additional space is required.
Last Name First Relationship
Date of Birth
(mm/dd/yyyy)
Home Address (Street, City,
State, Zip)
Phone
Number
% of
Benefit
Contingent Beneficiary: Designate the contingent beneficiary who will receive the benefits if the primary beneficiary has died at the time the benefit is
to be paid. It is important to include the correct home address and phone number.
Last Name First Relationship
Date of Birth
(mm/dd/yyyy)
Home Address (Street, City, State, Zip) Phone Number
Part 4 – Signature Required
I apply for the insurance for which I am now eligible (or for which I may become eligible) under the provisions of the Group Policy or Group
Policies issued to my employer by the Boston Mutual Life Insurance Company and authorize deductions, if any, from my earnings of the
required premium contribution toward the cost of the insurance. I UNDERSTAND THAT IF I AM DISABLED ON THE DATE MY
INSURANCE WOULD OTHERWISE BECOME EFFECTIVE, I SHALL ONLY BECOME INSURED ON THE DATE I RETURN TO
ACTIVE FULL-TIME WORK.
Deduction Authorization: I authorize the City of Boston, or the Boston Retirement Board, to deduct from my payroll or pension check the
amount required for the coverage I have selected.
Retirees must collect a pension from Boston retirement system to be eligible for City of Boston coverage.
Signature of Applicant Date Signature of Authorized Official Date
City of Boston
Basic Life Insurance Enrollment Form
Policy Number – 25373
Employee ID: _____________
Return completed form to
Health Benefits & Insurance Division
Boston City Hall, Room 807
Boston, MA 02201
Fax: 617-635-3932
