Get Loudoun County Public Schools - Loudoun K12 Va

This guide provides step-by-step instructions to assist users in accurately completing the Loudoun County Public Schools Health Insurance Election/Change Form and Salary Reduction Agreement. Whether you are a new hire or an existing employee, this guide will help you navigate the form with ease and clarity.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the form, which will open in your preferred editor.
2. In Step 1, indicate your reason for completing the form by checking all applicable boxes. Options include new enrollment, dependent addition, or canceling coverage. Provide the effective date for this action.
3. In Step 2, fill out your employee information, including your name, date of birth, phone number, email, and PID (personal identification number).
4. Skipping Step 3 is necessary if you are opting out of all coverage. If choosing to waive coverage, select to receive the $9.00 Opt Out Credit and proceed directly to Step 9 for acknowledgment.
5. In Step 4, select whether you want to enroll in a medical/prescription plan (Cigna OAP or Cigna POS). If enrolling, indicate your primary care physician's name if choosing the POS plan.
6. For Step 5, choose to enroll or waive dental insurance with Delta Dental. If enrolling, indicate your desired level of coverage.
7. Next, in Step 6, decide on vision insurance through Davis Vision, choosing either to enroll or waive coverage, along with the level of coverage if enrolling.
8. In Step 7, provide details for any dependents you wish to add. For each dependent, list their relationship, select the applicable coverage options, and ensure to attach the required documentation to substantiate their eligibility.
9. Lastly, complete Step 8 by reading the acknowledgment statement, signing the form with your name, and dating it appropriately. Ensure that all sections are completed and necessary documentation is attached before submission.

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