Get Open Enrollment Form

Filling out the Open Enrollment Form online is an essential step in selecting your benefits coverage. This guide provides clear, step-by-step instructions to help you navigate the form efficiently and ensure you provide all necessary information accurately.

Follow the steps to complete the Open Enrollment Form online:

1. Press the ‘Get Form’ button to access the Open Enrollment Form and open it in your editor.
2. Begin with the Employee Information section. Here, you will enter your details including location name, location number, last name, first name, home address, city, state, social security number, date of birth, home/cell phone number, email address, and zip code. Be sure to check that all your information is accurate.
3. In the Benefit Election(s) or Waiver of Medical Coverage section, indicate whether you wish to enroll yourself and any dependents in medical, dental, or vision coverage, following the group’s tiered structure. Specify who is to be covered (employee, spouse, child(ren)) and select the type(s) of coverage needed.
4. For each dependent, complete the required information including their name, social security number, birthdate, and sex. Additionally, indicate if they are a legal guardian, a step-child, or a disabled dependent.
5. If you choose to waive medical coverage, certify your eligibility and select the reason for your waiver. Provide details for individual policies or any other coverage you may have.
6. Fill out the Other Coverage/Authorization To Release Information section, providing information about your other employers or insurance coverages if applicable. This includes your spouse's details and their coverage status.
7. Review all sections of the form for accuracy and completeness. After ensuring everything is correct, proceed to sign and date the form at the designated spaces.
8. Finally, save changes to your form and choose to download, print, or share the completed document as needed.

Complete your Open Enrollment Form online today to secure your benefits!