F02367 Country Office Appointments - Household, MBP, and Optional Group Term Life / Dependent Life / AD&D Insurance Enrollment

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.

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Information on Completing the Form

  • Staff member completes Section 1 and Section 2 to elect plan type. Section 3 must be completed for all new staff appointments. All eligible dependents must be  declared, even if you elect not to enroll your eligible family members in the  MBP. Enrollments must be made within 60 days of joining the World Bank Group.
  • Staff member signs and dates form in Section 5, and gives form with supporting documentation to the CO MBP administrator or back up. For enrollmentrequiring approval by HR Operations (for example legal adoption or  registration of a domestic partnership) supporting documentation that are not in   English, an English translation must be provided.
  • CO MBP administrator or back up reviews documentation, verifies eligibility of  dependents, signs, and dates Section 6, and submits form with  supporting   documentation to the HR Operations (please select one transmittal format, and  submit only once): Fax: +1-202-522-7026   or   Email:  hroperations@worldbank.org

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 26 Jan 2024

Staff member's information

World Bank Group UPI*

First Name*

Last Name*

Middle Name

Marital Status*

Gender*

Birth Date*

Entry on Duty Date*

Select one Enrollment Event, followed by an MBP Option. Complete Section 3 if enrollment includes eligible family member(s)

Enrollment Event:

MBP Option:

Do you have spouse or domestic partner?*

Do you have children?*

Fill in your eligible family member(s) information according to the MBP option you have selected in Section 2

This section is mandatory when reporting one of these life events: marriage, birth, domestic partnership registration, legal adoption; even if you elect not to enroll your eligible family members in the MBP.

Eligible family member(s) for medical insurance when the enrollment deadline is met:

  •  Spouse or HR registered and approved domestic partner;
  •  Biological or legally adopted children under age 26 of the staff member or the spouse or domestic partner of the staff member (i.e., a step-child) that is registered with the World Bank Group;
  • Child of 25 years of age or older who meets the criteria of disability or handicap as determined and approved by the medical insurance administrator.

Spouse/Domestic Partner:

·   Domestic Partners must be reviewed and approved by the HR Operations before enrollment in the MBP

First Name*

Last Name*

Middle Name

Relationship*

Gender*

Birth Date*

City of Birth*

Country of Birth*

Nationality*

Enroll in RMBP?*

Children Information

First Name*

Last Name*

Middle Name

Relationship*

Gender*

Birth Date*

City of Birth*

Country of Birth*

Nationality*

Is child under age 26?*

Is child married?*

Do you pay at least 50% of child's support?*

Is the child a full time student?*

Enroll the child in MBP?*

Does the child reside in your household (student boarding at school/university are considered household residents)?*

Optional Insurance Coverage Election

  • Regular, open, and term appointments are eligible for Optional Insurance.

  If you wish to enroll in one of the Optional Insurance programs, choose from the options below. Please note that premiums for Optional insurance are paid by the individual staff member. Premium amounts can be found on myHR. If you do not wish to enroll,

leave them unchecked. Please ensure you designate insurance beneficiaries via myHR Self-Service or  Form F01603, if you do not have

  access to myHR Self-Service.

Staff Member Authorization and Signature

I, the undersigned, hereby apply for Medical Benefits Plan (MBP) enrollment for myself and eligible family members indicated above.  I understand that: (1) MBP enrollment for me is mandatory; (2) MBP enrollment for eligible family members is optional; and (3) if I do not enroll eligible family members within 60 days from entry on duty or life event (marriage, birth, or death), I can elect to enroll them during the annual open enrollment period held in November for coverage to start January of the following year.  I hereby authorize the World Bank Group to deduct from my earnings any required employee contribution for MBP coverage. I further agree to notify the World Bank Group of any changes affecting my own or my eligible family members' eligibility. I understand that this form is not valid until it is signed by the MBP administrator or back up in my country office.

I, the undersigned, hereby apply for Optional Insurance coverage as selected above. I understand that I am responsible for the full premium for any selected Optional Life Insurance. I hereby authorize the World Bank Group to deduct from my earnings any required employee contribution for any selected Optional Life Insurance. I understand that I may only enroll in or increase my Optional Life Insurance and Optional Dependent Life Insurance coverage within 60 days of entry on duty or a life event without undergoing the late enrollment process.

I, the undersigned, also certify that the information provided by me is complete and true. I understand that any misstatements regarding the use of benefits may result in disciplinary measures per Staff Rules 3.00 or 8.01. I agree to follow the MBP rules and regulations, in addition to Staff Rules applicable to the MBP.  I understand that the World Bank Group benefits, including the MBP, are subject to audit and I consent and authorize the release of any information needed for benefits administration to the World Bank Group or their representatives.

I understand that in the event of a conflict between this form and the Staff Rules, the Staff Rules will prevail. I understand that Optional Insurance coverage is subject to policy provisions, as described in the vendor’s life insurance policy.

Date

Signature

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.