State Employee Health Plan

EAC Committee Form


Health Care Commission


Employee Advisory Committee

Active State Employee Nomination Former

* Indicates a required field
EMPLOYEE DETAILS
Do you report directly to any current member of the Health Care Commission?:
SEHP Coverage Information
Medical Carrier:
Medical Plan:
Coverage Level:
Dental:
Vision:
Supplemental:
HealthQuest Participant:
Essay Portion
Demographic Information (Optional)
Gender:
Marital Status:
Children in Household:
Affirmation and Signature
If elected to the EAC, will you make yourself available to attend 3-4 meetings per year in person, per year in Topeka?:
*
 Print your name.
Draw your signature.
*
*
 Print your name.
Draw your signature.
*
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