| OGB Enrollment/Change Form (GB-01) |
| Form used to enroll or request a change with Louisiana Office of Group Benefits (OGB) |
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Handle:
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Document-4123
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Owner:
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Laiche, Karen (User-23, klaich:DocuShare)DS
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| Wednesday, December 15, 2010 08:43:50 AM CST |
| Friday, January 6, 2023 10:35:09 AM CST |
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Modified By:
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Laiche, Karen (User-23, klaich:DocuShare)DS
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Locked By:
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| - 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 ...
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| Allowed |
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Adobe Portable Document Format (.pdf) - application/pdf
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| OGB Enrollment- Change Form 2021 (GB-01) as of 7-22.pdf |
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| 4 |
| 184141 |
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| No |
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Appears In:
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ALL FORMS - Alphabetically Listed by Form Title
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DELGADO FORMS
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HUMAN RESOURCES FORMS
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Preferred Version:
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OGB Enrollment/Change Form (GB-01)
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DELGADO FORMS 
