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:
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