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OGB Enrollment/Change Form (GB-01)
Form used to enroll or request a change with Louisiana Office of Group Benefits (OGB)
Handle: Document-4123
Owner: Laiche, Karen (User-23, klaich:DocuShare)DS
Wednesday, December 15, 2010 08:43:50 AM CST
Friday, March 18, 2022 10:09:38 AM CDT
Modified By: Laiche, Karen (User-23, klaich:DocuShare)DS
Locked By:
  • Employee Name changed to: Annual Salary Agency Name I. LIFE INSURANCE (Check only one) No Coverage Employee/ Dependent BASIC BASIC PLUS SUPPLEMENTAL Employee/ No Dependent Coverage Employee/ No Dependent Employee/ Dependent Coverage Employee/ Dependent Coverage Eligible Spouse$ 1, 000 Eligible Child$ 00 Eligible Spouse$ 2, 000 Eligible Child$ 1, 000 Employee/ Dependent Coverage Employee/ Dependent Coverage Eligible Spouse$ 2, 000 Eligible Child$ 1, 000 Eligible Spouse$ 4, 000 Eligible Child$ 2, 000 ...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
OGB Enrollment- Change Form 2021 (GB-01) as of 3-18-222.pdf
4
175325
No
Appears In: ALL FORMS - Alphabetically Listed by Form Title DELGADO FORMS HUMAN RESOURCES FORMS
Preferred Version: OGB Enrollment/Change Form (GB-01)