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:
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.