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Enrollment Form

To apply, please complete all applicable sections of this form and click "send." When we receive your application, we will call you to complete the process, which will require your signature. You may also call Toll Free 1-888-400-9303 -- In Baton Rouge, call 400-9303
** IMPORTANT: Form items marked in BLUE TEXT are required fields.
*** Not all State agencies are eligible for this program and the rates listed. Members of the LSU System, other State Universities, Community Colleges, Public School Systems, and the Louisiana Community and Technical College System have their own payroll systems and are not included. Please contact Starmount or your Human Resources Representative with any questions.
Insurance Type:
Select:            If you are currently enrolled in Starmount's Dental Plan, you only need to elect vision coverage.
Select Vision Plan:                If you you have chosen to enroll in a Vision plan, please choose which type.
Department Information:
Department Name:
Location:
 
Employee Information:
Coverage Level:
 
Sex:
Last Name:
First Name:
M.I.:  
Date of Birth
(MM/DD/YYYY):
Social Security
Number:
 
Home Street Address:
Email Address:
 
Home Phone:
City:
State:
Zip Code:
 
Work Phone:
Fax Number:
   
Family Information: (only those eligible may be enrolled)
SPOUSE:
Sex:
Last Name:
First Name:
M.I.:  
Date of Birth
(MM/DD/YYYY):
DEPENDENTS:






Comments & Questions:
 

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.