F01997 Enrollment/Payroll Deduction Authorization To Change Medical Insurance Plan Enrollment (Bank/Bank Couple)

Instructions:

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

1) Return all pages of this form to HR Operations (Select one transmittal format, and submit only once):

a.  E-mail at hroperations@worldbank.org          

b.  Fax +1 (202) 522-7026

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 25 Apr 2023

Staff Member's Information

For the purposes of this form, the word “spouse” means a spouse or a registered domestic partner eligible for MIP coverage from the World Bank Group in his/her own right who is currently a dependent under the MIP coverage of his or her spouse/partner.

UPI of current primary MIP member*

Name:*

UPI of spouse who will become primary MIP*

Name:*

To be completed by spouse who is currently the primary MIP member:

I elect to withdraw from the MIP as of the last day of the month in which this form is received by the HR Operations. Enrollment will be switched to my spouse’s name and UPI. I understand that enrollment in the MIP at a later date is not automatic. I understand that if I wish to enroll at a later date, I must do so before my spouse, as listed below, ceases his/her MIP enrollment, or I must furnish, at my own expense, evidence of good health satisfactory to the insurance administrator for myself and my eligible family member(s). The insurance administrator may or may not accept the application if the evidence is not satisfactory.

Withdrawing Staff Member ‘s Signature

Date

To be completed by spouse who will enroll as primary MIP member:

I authorize a change in MIP enrollment, and corresponding payroll deductions, from my spouse named above to myself. I understand that enrollment will be effective from the first of the month after receipt of this form by the HR Operations. Enrollment will be under the same coverage (Individual/Dual/Family) and Option (A, B, C) that my spouse had elected. I agree to notify the HR Operations of any change affecting my own or my eligible family members' eligibility.

Direct Deposit Option:*

Enrolling Staff Member ‘s Signature

Date

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.