enrollment form
'vVageWorks\•/ everyon.e ben.ef1ts·
Osage Nation Constituent Services 239 West 12th Street, Pawhuska, OK 74056 Phone(918)287-5555 Fax(918)287-5221 [email protected]
Limited Health Benefit Plan
a
Please check here if this enrollment is being Requested by a NON-Osage Custodial Parent: Requester - PRINT YOUR NAME HERE:___________________
Initial Enrollment Request for 2018
Tribal Member - lndividu I or Family
1. If you are enrolled as a member of the Osage Nation and requesting to enroll in this benefit plan, please complete this form Please print and use ink. 2. You must include a copy of your Tribal Membership Card in order to b
Osage Nation Constituent Services 239 West 12th Street, Pawhuska, OK 74056 Phone(918)287-5555 Fax(918)287-5221 [email protected]
Limited Health Benefit Plan
a
Please check here if this enrollment is being Requested by a NON-Osage Custodial Parent: Requester - PRINT YOUR NAME HERE:___________________
Initial Enrollment Request for 2018
Tribal Member - lndividu I or Family
1. If you are enrolled as a member of the Osage Nation and requesting to enroll in this benefit plan, please complete this form Please print and use ink. 2. You must include a copy of your Tribal Membership Card in order to b
