Louisiana State University
2013 Annual Enrollment Form
We show your current address as:
Agency Code:
LSU ID#:
Dept Code:
Is this address correct?
If no, please make corrections in the space below and sign form in appropriate space.
________________________
________________________
________________________
Note: It is the responsibility of the plan member to notify LSU of a change in address.
Plan members who do not notify LSU of a change in their address assume responsibility for
not receiving plan information, ID cards, or voting materials that are mailed to them.
We show your current level of medical coverage as:
If this information is incorrect, please contact your campus HRM representative. (List below)
If you wish to CHANGE YOUR CURRENT PLAN CARRIER , please select from the options below.
If you do not wish to make a change, you do not need to return this form.
____Blue Cross PPO *nationwide
____Blue Cross HMO *nationwide
____ Blue Cross High Deductible Health Plan HDHP-HSA *nationwide
____Vantage Medical Home (HMO) * Baton Rouge, Alexandria, Shreveport, Monroe, and Lake Charles areas
____ LSU First Option 1
____LSU First Option 2
By completing and returning this form you are requesting a change in your present health plan coverage offered to active employees and
retirees of the state of Louisiana.
Plan Member Signature (Blue or Black ink)
Date
Agency Rep. Signature
Remit form to your HRM representative
Questions?? Call LSU HRM for your campus for questions on coverage:
LSU A & M
LSU A & M
LSU Ag Center
LSU Ag Center
LSU Ag Center
LSU Eunice
Amy Amoroso
Chris Newton
Kathy Loyd
Kristen Manes
Katie Hay
Caletta Soileau
225-578-8200
225-578-8200
225-578-8229
225-578-4629
225-578-4631
337-550-1202
Law Center
LSU System
Pennington
Pennington
LSU Alex
LSU Alex
Frank Adair
Jennifer Christian
Courtney Henson
Sharon Hebert
June Guillory
Nikki Tam
225-578-8586
225-578-7438
225-763-2776
225-763-3024
318-473-4419
318-473-6558