Follow the steps to successfully complete the benefits enrollment form.

1. Press the ‘Get Form’ button to access the enrollment form and open it in your editor.
2. Begin with the employee information section. Enter your last name, first name, middle initial, street address, city, state, zip code, employee ID, work phone, home phone, email address, and date of birth in the specified format.
3. Indicate the reason for enrollment or change by selecting one of the provided options. Make sure to fill in the date of employment or change properly. Remember that changes can only be made under certain conditions.
4. For medical election, choose whether you are enrolling in a medical plan or waiving medical coverage. Then, select your level of coverage from the available options based on your needs.
5. Specify your group term life insurance coverage amount. You must select a level of coverage as waiving is not an option. Additional information may be required, so refer to the Enrollment Guide if necessary.
6. Complete the employee and dependent information section if you are electing a coverage level that includes dependents. Fill in their names, activities, and dates of birth. Additionally, indicate whether to add or delete them from medical coverage.
7. In the employee signature section, acknowledge and agree to the terms of the benefits selected. Provide your signature and date to confirm that the information you provided is true and accurate.
8. After reviewing the completed form for accuracy, you can save your changes, download, print, or share the form as needed.

Complete your benefits enrollment form online today to ensure you secure your benefits.