F02367A Country Office Appointments - Household, MBP, and Optional Group Term Life / Dependent Life / AD&D Insurance Enrollment

Instructions:                 

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Information on Completing the Form

  • Use this form to report marriage/divorce/birth/death/domestic partnership/adoption/step child.
  • Enrollment and reporting of life events must be made within 60 days of joining the World Bank Group or the life event.
  • Supporting documentation that are not in English, a translation must be provided.
  • Staff member signs, dates, and submits the form to HR Operations (please select one transmittal format, and submit only once): Fax: +1-202-522-7026   or  Email:  hroperations@worldbank.org submit only once): Fax: +1-202-522-7026   or   

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*

Add Eligible Family Member

  • Enrollments and reporting of life events must be made within 60 days of joining the World Bank or life event.

Do you have spouse or domestic partner?*

Do you have children?*

Information for 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)?*

Change in Enrollment - Remove Eligible Family Member(s) 

I certify by my signature below that I will give my former spouse/child all MBP continuation information so that my former spouse/child may apply for MBP continuation within the prescribed period of time (60 days from end of MBP coverage).  I further certify by my signature that I am responsible for reimbursing the World Bank Group for any MBP claims paid on behalf of my former spouse/child after the end of MBP overage date for my former spouse/child. 

For the required supporting documentation please refer to the checklist .   

First Name*

Last Name*

Middle Name

Reason:*

Effective Date:*

Remove Dependents from:*

MBP Enrollment 

Complete Section 4 if the Life Event changes your MBP coverage.

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.
  • Death of staff members spouse/ Dependent children.

MBP Option:

Optional Insurance Coverage

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

If you wish to change your Optional Life Insurance coverage, you may decrease it at any time. You may increase it by one times net annual salary within 60 days of a life event without undergoing the late enrollment process. Please ensure your beneficiaries are up    to date. You can check your beneficiaries through the myHR Self-Service portal. To make beneficiary changes, please use Form F01603.

 Optional Life Insurance

If elected, you may opt-out of your Optional Dependent Life Insurance at any time. You may enroll within 60 days of a life event without undergoing the late enrollment process.

Optional Dependent Life Insurance:

If you elected, you may opt-out of your Optional Individual Accidental Death and Dismemberment Insurance at any time. You may enroll at any time

Optional Individual Accidental Death and Dismemberment Insurance:

Section 6:   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 your 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.