Benefits Enrollment / Change Form
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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
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