Get Az Benefit Enrollment/change Form - City Of Mesa 2020-2025

Filling out the AZ Benefit Enrollment/Change Form for the City of Mesa is a straightforward process that allows users to enroll in or change their benefits. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Start with the employer section by checking the appropriate box for either new hire or qualifying event. Provide the details of the qualifying event if applicable and indicate whether you are full-time, part-time, or a retiree. Fill in the benefit effective date and your date of hire.
3. Enter your member information, including your last name, first name, middle initial, street address, employee ID number, and your city, state, and zip code. Provide your home and work phone numbers, marital status, date of birth, gender, and Social Security number.
4. Choose your medical/prescription drug coverage by selecting one plan from the options provided. Ensure to review each plan's details before making your choice.
5. Next, select your dental coverage by picking one option from the dental coverage election section.
6. Choose your vision coverage by selecting one plan from the vision coverage election section, just like the dental options.
7. For supplemental life insurance, indicate whether you wish to enroll or decline. Provide coverage election details for yourself, your partner, and any dependent children.
8. If applicable, complete the voluntary short-term disability section by choosing your plan election and coverage amount.
9. Fill out the flexible spending account section by choosing whether to enroll or decline, and specify the coverage amounts for both medical and dependent care reimbursement accounts.
10. In the dependent information section, list all dependents, their relationship to you, gender, last name, first name, middle initial, date of birth, and Social Security number as required.
11. Review the agreement and signature section, ensuring that you understand that documentation is required for coverage activation. Sign and date the form.
12. Finally, save your changes, download a copy for your records, and if necessary, print or share the form with the appropriate office.

Complete your documents online today to ensure you have the necessary benefits coverage.