Get Payroll Auth

Filling out the Payroll Authorization form is an essential step in managing your dental and vision benefits. This guide will provide you with clear, concise instructions to complete the form accurately and efficiently.

Follow the steps to fill out the Payroll Auth online

1. Press the ‘Get Form’ button to access the Payroll Authorization form and open it in your online editor.
2. In the top section, fill in the 'Group Name', 'Effective Date', 'Date of Hire', and 'Telephone #' fields.
3. Indicate your employer by checking the appropriate box—'Comm. Of MA', 'Bristol County', 'Dukes County', or 'Plymouth County'.
4. Provide your 'Social Security Number', 'Last Name', 'Home Address', 'DOB' (Date of Birth), 'Sex', 'City', 'State', and 'Zip Code' in the designated fields.
5. List all legal dependents under your plan in the section provided. Ensure to include their 'First Name', 'Last Name' (if different), 'Date of Birth', 'Sex', and check the box if the dependent is over 19 and a full-time student.
6. Select the reason for submission by checking one box: 'New Enrollment', 'Name/Address Change', 'Add Dependent(s) to Plan', 'Coverage Level Change', 'Remove Dependent from Student Status', 'Add Dependent to Student Status', or 'Terminate Coverage'.
7. If applicable, specify 'Vision Plan Selected' by choosing between 'EyeMed Vision Plan' or 'Correctional Industries Voucher Plan'.
8. Read and sign the certification statement to confirm that all information provided is true and correct to the best of your knowledge.
9. Authorize your employer to deduct the specified amount from your pay for coverage by filling in the 'Payroll Deduction' box.
10. Complete the form by including your 'Employee Signature', 'Administrator Authorization', and the respective 'Date'.
11. Once all sections are completed, save your changes, and proceed to download, print, or share your form as needed.

Complete your documents online today!