This form is used to enroll in the Benefit Plan or to make changes during open enrollment periods. Eligibility requirements must be met.
If you have not already requested information on the benefits available, you may do so here: Request Benefit Information
Benefit information will be emailed to you separately.
Please make your benefit selections below.
If you selected either the Dependent or Family plan for either of the previous options, please provide the necessary dependent information:
SHORT TERM DISABILITY
NON WORK RELATED SICKNESS AND ACCIDENT BENEFIT
I authorize my employer to withhold the amount required from each paycheck in order to fund the benefits I have elected. Payroll deductions will begin the first payroll dated in the month of coverage. I further understand that due to IRS regulations, I may not cancel or change any elected benefits until the next annual open enrollment period unless I have a life status change.
These elections are subject to determination of eligibility as required by the Plan.