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Benefits Enrollment Template




Benefits Enrollment Form



Benefits Enrollment / Change Form


Enrollment Request

[__] New Hire [__] Newly Eligible [__] Rehire

[__] Beneficiary Update

[__] Qualified Life Event (QLE): Date of Event: ____/____/______

Enroll / Add

Employee:

[__] Change in legal marital status

[__] Loss of eligibility or other coverage

[__] Returns from unpaid leave

[__] Moves into plan service area

Spouse / Domestic Partner:

[__] Change in legal marital status

[__] Loss of eligibility or other coverage

[__] Moves into plan service area

Child(ren):

[__] Birth

[__] Adoption

[__] Foster Care

[__] Legal Guardianship

[__] Loss of Eligibility or Other Coverage

[__] Moves into Plan Service Area

[__] Qualified Medical Child Support Order

Remove

Employee:

[__] Change in legal marital status

[__] Gains other coverage

[__] Begins unpaid leave

[__] Moves from plan service area

[__] Death

Spouse / Domestic Partner:

[__] Change in Legal Marital Status

[__] Gains Other Coverage

[__] Dissolves Domestic Partnership

[__] Moves From Plan Area

[__] Death

Child(ren):

[__] Reaches Age 26

[__] Gains Other Coverage

[__] Dissolves Domestic Partnership

[__] Moves From Plan Service Area

[__] Death

Miscellaneous:

[__] Cancel Dependent Life

[__] Cancel Short Term Disability

[__] Change in Day Care Expense or Provider

[__] Non-payment of Premiums During Leave

[__] Eligible for LTD Benefits

[__] Other / Please Explain

________________________________

Dependent Information

Last Name:

________________________________

First Name and M.I.:

________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee: ____________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Last Name:

________________________________

First Name and M.I.:

________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee:

________________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Last Name:

________________________________

First Name and M.I.:

________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee: ____________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Health Plans

Medical Plans [__] Enroll [__] Decline / Cancel [__] Change [__] No Change

EPO

Provider Networks [__] Aetna [__] CIGNA [__] United Health Care

Coverage Level [__] Employee[__] Employee+Adult [__] Employee + Child [__]Employee+Family

PPO

Provider Networks [__] Aetna [__] CIGNA [__] United Health Care

Coverage Level [__] Employee[__] Employee+Adult [__] Employee + Child [__]Employee+Family

Aetna HSA Option [__]Employee[__]Employee+Adult [__]Employee + Child [__]Employee+Family

Dental Plans

Delta Dental [__] Employee[__] Employee+1 [__]Employee + Family

Total Dental Administrators [__] Employee[__] Employee+1 [__]Employee + Family

Vision Plans

Avesis Advantage [__] Employee[__] Employee+1 [__]Employee + Family

Print Name:

________________________________

Signature:

________________________________

Employee ID#:

________________________________

Email Address:

________________________________

Date: ____/____/______

For Assistance, please contact the Office of Human Resources Employee Service Center





Word

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