Get 2012-13 Plan Year Enrollment Form - State Of Oregon - Oregon

This guide provides clear and detailed instructions to assist users in completing the 2012-13 Plan Year Enrollment Form for the State of Oregon online. Whether you are enrolling for the first time or updating your information, this can be done efficiently and accurately.

Follow the steps to successfully complete your enrollment form.

1. Press the ‘Get Form’ button to obtain the enrollment form and open it in your editor.
2. Fill in your personal information in the Employee Information section. This includes your last name, first name, middle initial, birth date, gender, and contact address. Ensure that you check the box if you are using a new address.
3. Indicate your ethnicity and race by selecting the appropriate options. Be sure to circle your primary race selection.
4. Enter your Employee ID, Social Security Number, or E Number, and provide your work email, personal email, work phone, and home phone. Review all information for accuracy.
5. In the Dependent Information section, input the details of any dependents you wish to enroll. For each dependent, include their last name, first name, middle initial, birth date, gender, ethnicity, race, relationship codes, and any additional address details as necessary.
6. Continue listing additional dependents in the provided spaces or on attached sheets, if required. Ensure that all information is filled out clearly.
7. In the Medical, Dental, and Vision Plan Selection section, write in your choices for each plan. You may opt out, waive, or decline coverage as applicable, but be aware of the consequences of your selections on future enrollment.
8. If choosing to opt-out of medical coverage, complete the Other Group Coverage section with the necessary details and ensure to provide proof of other coverage to your educational entity within the specified time frame.
9. For Optional Insurance, choose any additional insurance you wish to enroll in, including life insurance and accidental death and dismemberment coverage. Indicate new enrollment, changes, or declines as applicable.
10. Complete the Beneficiary Designation section by listing beneficiaries and their percentages. Ensure the totals for primary and contingent beneficiaries equal 100%.
11. Fill out the Voluntary Disability Insurance section, indicating whether you will enroll or decline coverage.
12. Sign and date the Employee Signature and Authorization section to confirm that all information provided is true and accurate.
13. Submit the completed form to your educational entity. Do not send the form directly to OEBB.

Complete your enrollment form online today to ensure your benefits coverage is secure.