F01998 Enrollment and Payroll Deduction Authorization To Change Medical Benefits Plan Enrollment (Bank/Bank Couple)

Instructions:

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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 MBP coverage from the World Bank Group in his/her own right who is currently a dependent under the MBP coverage of his or her spouse/partner.

UPI of current primary MBP member*

Name:*

UPI of spouse who will become primary MBP*

Name:*

To be completed by the Staff Member who is currently enrolled in the MBP. 

I elect to withdraw from the MBP as of the last day of the month in which this form is received by the HR Service Center. Enrollment will be switched to my spouse's name and UPI#. I understand that enrollment in the MBP 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 MBP enrollment, or I must furnish, at my own expense, evidence of good health satisfactory to the insurance administrator for myself and my dependents. 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 the Staff Member who is requesting enrollment in the MBP.

I authorize a change in MBP enrollment, and corresponding payroll deductions, from my spouse named above to myself. I understand that the 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 code (B, C or D) that my spouse had elected. I agree to notify the HR Operations of any change affecting my own or my dependents' eligibility.

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.