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.

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