Get Open Enrollment Form

This guide will provide you with clear and concise instructions on how to complete the Open Enrollment Form online. Following these steps will ensure that your benefits are effectively managed and tailored to your needs.

Follow the steps to complete your enrollment process.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by checking the appropriate box indicating if this is for initial enrollment, open enrollment, special enrollment, employment status change, or to cancel coverage. Make sure to enter the relevant dates for marriage, birth/adoption, or any other changes.
3. Fill out the employee information section including your last name, first name, initial, social security number, physical and mailing addresses, home and work phone numbers, email address, date of birth, date of hire, effective date, marital status, and sex.
4. In the benefits elections section, refer to the benefits guide for rates. Select the coverage options you are choosing for medical, dental, and vision, while indicating if you are waiving any coverage.
5. List any eligible dependents and their information, including name, gender, social security number, date of birth, and their relationship to you. Indicate whether you are enrolling, canceling, or changing any coverage for each dependent.
6. If applicable, provide information on any other insurance coverage that you or your eligible dependents may have, including insurance company name, group number, and policy number.
7. Enter your elections for flexible spending accounts indicating the amounts for healthcare and dependent care spending accounts.
8. Fill in your elections for voluntary life and accidental death and dismemberment insurance, ensuring to follow any additional requirements if applicable.
9. Review the certification and authorization section. Ensure you understand the deductions and policies outlined, and sign and date the form as required.
10. Once completed, save your changes, and you can download, print, or share the form as necessary.

Get started today by filling out your Open Enrollment Form online!