Blind Vendor Health Insurance Enrollment Form

This is a health insurance enrollment form document issued by the Nevada Department of Employment, Training and Rehabilitation (DETR) Business Enterprises of Nevada (BEN) program. The form requires blind vendors participating in the BEN program to provide comprehensive dependent information, including names and dates of birth for up to four dependents and their relationships to the vendor. The form requests current health insurance details, including the carrier name, address, phone number, and policy identification or enrollment numbers, along with a list of covered dependents. The document references Bureau Policy #02-10, which mandates that vendors supply supporting documentation including birth records, marriage licenses, and Social Security numbers for each dependent, with additional proof of enrollment required for dependents over eighteen years old who are enrolled in post-secondary education programs.

This enrollment form serves as an administrative document within the broader BEN Case Management System procurement initiative, which is designed to standardize workflows and operations for blind and visually impaired food service and vending business operators throughout Nevada. The form appears to have been revised as of May 30, 2019, and functions as a key component of vendor documentation requirements within the program's operational framework, ensuring proper verification and tracking of dependent coverage for enrolled blind vendors.