Get Employee Election Form - - - Group Benefit Services

Filling out the EMPLOYEE ELECTION FORM is an essential process for enrolling in your employer's benefit plans. This guide will provide you with step-by-step instructions to successfully complete the form online, ensuring you make the right selections for your needs.

Follow the steps to complete the EMPLOYEE ELECTION FORM.

1. Click the ‘Get Form’ button to obtain the EMPLOYEE ELECTION FORM and open it for editing.
2. Begin with the Employee Information section. Fill in your last name, first name, middle initial, Social Security number, street address, city, state, zip code, date of birth, sex, hours worked per week, and contact numbers. Your employer will complete the shaded boxes, so ensure you leave those blank.
3. In the General Information section, provide your dependents' last name, first name, middle initial, Social Security number, sex, date of birth, and select their primary care provider number if applicable. Indicate if they are current patients, tobacco users, and their dental code. Answer yes or no regarding dental, vision, and medical coverage.
4. Complete the Other Health/Dental Insurance Information section. Indicate whether you or your dependents have other health or dental insurance, providing effective dates and policy numbers. Specify who is covered and the source of your other coverage.
5. In the Election of Coverage section, choose your preferred medical, dental, vision, and life insurance plans. Make sure to indicate individual or family coverage as per your needs.
6. Fill out the Life Insurance Beneficiary section by naming the beneficiary, specifying their relationship to you, and indicating the percentage of benefit.
7. Read and acknowledge the important information regarding the debit card usage and waiver information. Make sure you understand the binding nature of your elections.
8. If opting out of benefit coverage, fill out the Waiver section and provide the reason for declining coverage, along with the name of your current insurance carrier.
9. Confirm your enrollment by signing the form and dating it. Ensure that your employer’s representative also signs for verification.
10. After completing the form, save your changes, and if needed, download, print, or share the EMPLOYEE ELECTION FORM as required.

Complete your EMPLOYEE ELECTION FORM online to secure the benefits you deserve!