AGENCY: Box Elder County School District (Utah). Department of Business Administration

SERIES: 14757
TITLE: Health and accident insurance enrollment record
DATES: 1950-
ARRANGEMENT: Alphabetical by employee name

DESCRIPTION: Application forms completed by district employees enrolling into health and accident insurance. The original is sent to the insurer. Includes district name; specific job title; date of employment; policy number; employee name, social security number, address, birthdate, telephone number(s); beneficiary and contingent beneficiary and relationships; information on other insurance and employment; information of coverage requested; optional waiver of group insurance; listing of family members to be covered containing name, sex, birthdates, physicians names and addresses; employee's signature authorizing deductions for insurance; date; effective date and approval signature.

RETENTION

Retain until final action

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 09/1995

FORMAT MANAGEMENT

Paper: Retain in Office until insurer changed or employee termination and then destroy.

APPRAISAL

Administrative

This disposition is based on the administrative needs expressed by the office.

PRIMARY DESIGNATION

Private

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