Benefit Election Form
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.

EMPLOYEE PERSONAL DATA

BENEFIT SELECTIONS

Please make your benefit selections below.
DENTAL CARE
VISION

DEPENDENTS

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
STDA

TERM LIFE INSURANCE

If selected, you must include your beneficiary information.
LIFE

SIGNATURE

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.