Get 2012 Open Enrollment

Completing the 2012 OPEN ENROLLMENT form is an important step in securing your medical, dental, and vision insurance options. This guide will provide you with clear, user-friendly instructions to help you easily fill out the online form and ensure that you submit all necessary information correctly.

Follow the steps to complete your enrollment form effectively.

1. Click the ‘Get Form’ button to access the enrollment form and open it in your browser.
2. Begin by entering your name, including your last name, first name, and middle initial. Then provide your Social Security Number (SSN) and current address, including city, state, and zip code.
3. Indicate your date of employment, employment status (full-time or part-time), marital status (single or married), and your date of birth.
4. Fill in your home phone number and employee number where indicated.
5. For medical, dental, and vision insurance, select the type of coverage you are applying for: choose between different PPO options or waive coverage. Specify the level of coverage needed (employee only, employee + child(ren), employee + spouse, or employee + spouse + child(ren)).
6. If applicable, indicate whether you are under a Qualified Medical Child Support Order (QMCSO). If yes, provide the names of any dependent child listed.
7. Complete the information for each covered dependent, including their last name, first name, middle initial, Social Security Number, relationship to you, and date of birth. Include any additional required information if they are handicapped or a stepchild.
8. Indicate whether you or any dependents have other medical insurance. If yes, provide the details including the policy holder, policy number, name of the insured on the policy, insurance company name, and type of coverage.
9. If you or any dependents are entitled to Medicare, specify the name, Medicare number, reason for entitlement, and effective date.
10. Carefully read the attestation statement, confirming that all information provided is accurate. Sign, print your name, and date the form.
11. If you choose to waive medical/dental/vision insurance, sign and print your name in the waiver section.
12. Once you have filled out the form completely, save any changes you have made. You can then download, print, or share the completed form as needed.

Complete your 2012 OPEN ENROLLMENT enrollment form online today!