Follow the steps to accurately complete your benefits election form.

1. Click the ‘Get Form’ button to access the online form and open it in your selected editor.
2. Section A requires you to provide personal employee data. Fill in your Social Security Number, Employee ID, and full name, ensuring your mailing address, phone number, and email address are accurate.
3. Indicate your gender, date of birth, and any changes to your employee information, such as name corrections. Provide information on your eligibility coverage status and any previous insurance coverage.
4. In Section B, select the action relevant to your situation, such as 'Retiree RTW' for retirees returning to work or a relevant status change.
5. Complete Section C by inserting the reason code and event date for any life events impacting your insurance changes.
6. Section D involves selecting benefits options. Choose your health, dental, and vision coverage options and note any dependents you wish to add or drop.
7. In Section E, provide personal data for each dependent, including the relationship, names, birth dates, and any related tobacco-use certifications.
8. Read through Section F carefully, then authorize and sign the form. Ensure the date of your signature is provided.
9. Finally, save your changes, then download, print, or share the form as necessary while ensuring a copy is retained for your records.

Start completing your benefits election form online today!