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1043 enrollment app indd - state tn

1043 enrollment app indd - state tn-2025

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The document is an enrollment change application for the State of Tennessee Group Insurance Program, detailing procedures for adding, changing, or terminating health, dental, and vision coverage. It includes sections for employee information, coverage selection, dependent information, and required documentation for qualifying events. The document emphasizes the importance of providing accurate information and outlines the consequences of false reporting. Additionally, it describes the Partnership Promise requirements for members enrolled in specific health plans.

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Click ‘Get Form’ to open the 1043 enrollment application in the editor.
In Part 1, select the type of action you wish to take by marking the appropriate box for adding, changing, or terminating coverage. Specify which coverage is affected (Health, Dental, Vision) and indicate the participants affected (Employee, Spouse, Child(ren)).
Proceed to Part 2 and fill in your personal information including your name, Social Security Number, date of birth, and contact details. Ensure all fields are completed accurately.
In Part 3 through Part 5, select your desired health, dental, and vision coverage options. Choose from the available plans and premium levels based on your needs.
If applicable, provide dependent information in Part 6. Attach additional sheets if necessary for more dependents.
Finally, review all entries for accuracy before signing in Part 7. Submit the completed form to your agency benefits coordinator.

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What benefits do Tennessee state employees get?

Employee Benefits Health Insurance. Dental Insurance. Life Insurance. The Tennessee Plan (Supplemental Medical Insurance for Retirees with Medicare) Pharmacy Benefits. Vision Insurance. Disability Insurance (long term and short term)

What do I need to get a gold star on my drivers license in Tennessee?

You will need to present the following documents when applying for a REAL ID: Proof of U.S. citizenship or legal presence. Proof of your full Social Security Number. Two proofs of Tennessee residency.

How long do you have to work for the state of TN to get a pension?

After a five-year vesting period, an employee becomes eligible to receive a monthly benefit at retirement once the age requirement is met. The benefit is calculated by the employees years of service and salary. The benefit provided by TCRS is a solid foundation for building a retirement future.

What are the benefits of working for the state of Tennessee?

State employment affords employees a full benefits package that includes, health, dental and vision insurance; life insurance; opportunities to participate in deferred compensation plans; retirement benefit; Employee Assistance Program; workers compensation; paid leave as well as many other programs that can enhance an

Do TN state employees get bonuses?

A: Yes. The system establishes a certain increase to an employees base salary based on his or her performance. Those employees receiving an Advanced or Outstanding will receive an additional one-time, non-recurring performance bonus.

Do TN state employees get discounts?

The State of Tennessee Employee Discount Program exists to offer state employees discounts on products and services from various vendors in order to express appreciation for the valued service state employees provide Tennessee citizens.

1043 enrollment app indd - state tn-2025

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