Form Examples

State
Change Category Description
Add Coverage Adding Child(ren) - After the Event (Adoption, Birth, Legal Custody, Guardianship of Minor)
Adding Child(ren) - Before the Event (Adoption, Birth, Legal Custody, Guardianship of Minor)
Loss of Coverage - Enrolling as "Late Entrant"
Marriage - Add Dependent(s) - After the Event
Marriage - Add Dependent(s) - Before the Event
Cancel Coverage Cancel Dependent(s)
Cancel Spouse due to Divorce
Death and Survivor Death of Dependent(s)
Survivor - Retain Medical Coverage
Leave of Absence Continue Coverage
Cancel Coverage
Long-Term Disability Add Coverage
Cancel Coverage
Go to State Spouse's Coverage - Subscriber Form (Include Spouse's M-2 Form. See next Example.)
Go to State Spouse's Coverage - Spouse Form (Include Spouse's M-2 Form. See previous Example.)
Personal Information Changes Address Change
Name Change
Retirement Add Coverage
Continue Coverage
Go to State Spouse's Coverage - Subscriber Form (Include Spouse's M-2 Form. See next Example.)
Go to State Spouse's Coverage - Spouse Form (Include Spouse's M-5 Form. See previous Example.)
Terminate or Decline Coverage
Terminate State Employment - Non-Vested Cancel Coverage
Go to State Spouse's Coverage - Subscriber Form (Include Spouse's M-2 Form. See next Example.)
Go to State Spouse's Coverage - Spouse Form (Include Spouse's M-2 Form. See previous Example.)
Terminate State Employment - Vested Add Coverage
Cancel Coverage
Continue Coverage
Go to State Spouse's Coverage - Subscriber Form (Include Spouse's M-2 Form. See next Example.)
Go to State Spouse's Coverage - Spouse Form (Include Spouse's M-8 Form. See previous Example.)
Transfer Transfer of Employee to State Agency