Enrollment Forms - Adding & Dropping Dependents

Outside of the annual Open Enrollment period, you can make changes to your enrollment if you have a Qualifying Life Event

You can submit your request for a qualified benefit election or change to your benefits by phone, in person (no appointment necessary) or by submitting a completed Enrollment Form (mail, fax or drop off at our offices). See our Contact Us page for more information.


Start by selecting the Form that corresponds with your employer:


Required Documentation

Please note that certain enrollment elections require documentation in order to be processed (see the back of each Form for a list of the specific documents required). 

Required documentation may include COPIES of (please DO NOT send original documents):

  • Birth Certificate (for children and newborns)
  • Marriage Certificate or Certificate of Domestic Partnership 
  • Medicare Care, if retired, and Medicare eligible 
  • Evidence of other coverage with name of the individuals covered, the type of coverage (e.g medical, dental) and the termination or effective date of coverage


Do not send us any original documents like marriage or birth certificates. We cannot return submitted documents.