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.To view a summary of benefits available click here. You may also request this information be mailed to you by filling out: Request Benefit Information. Benefit information will be emailed to you separately. To enroll in AFLAC coverage click here: EMPLOYEE PERSONAL DATA First Name & M.I. Last Name Soc Sec Number Date of Birth Estimated working hours per week: BENEFIT SELECTIONS Please make your benefit selections below. DENTAL CARE Single - PLAN 1 Dependent - PLAN 1 Family - PLAN 1 Single - PLAN 2 Dependent - PLAN 2 Family - PLAN 2 VISION Single Family DEPENDENTS If you selected either the Dependent or Family plan for either of the previous options, please provide the necessary dependent information: First Name and M.I. Last Name Relationship Birth Date Soc Sec Number Add Remove SHORT TERM DISABILITY NON WORK RELATED SICKNESS AND ACCIDENT BENEFIT STDA * Yes No TERM LIFE INSURANCE If selected, you must include your beneficiary information. LIFE * Yes No Full Name Relationship Soc Sec Number 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. Signature Clear These elections are subject to determination of eligibility as required by the Plan. Date Submit