EAC Committee Form

Name:

Email:

Telephone:

County of Residence:

County of Work:

Job Title:

Years in State Service:

State Agency:

Do you report directly to any current member of the Health Care Commission?:

Yes

No

Agency Address:

Medical Carrier:

Aetna

BCBS

Medical Plan:

Plan A

Plan C

Plan J

Plan N

Coverage Level:

Employee Only

Employee + Spouse

Employee + Children

Employee + Family

Dental:

Elected Dental

Waived Dental

Vision:

Elected Vision

Waived Vision

Supplemental:

Elected Supplemental

Waived Supplemental

HealthQuest Participant:

Yes

No

Some

Gender:

Male

Female

Other

Prefer Not to Answer

Age:

Marital Status:

Single

Married

Common Law

Prefer Not to Answer

Children in Household:

0

1

2+

Prefer Not to Answer

If elected to the EAC, will you make yourself available to attend 3-4 meetings per year in person, per year in Topeka?:

Yes

No

Employee's Signature:

*

Print your name.

Draw your signature.

Clear Signature

Date:

*

Signature of Employee’s Supervisor or HR Officer Authorizing Participation:

*

Print your name.

Draw your signature.

Clear Signature

Date:

*

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