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Enrollment Forms/Adding & Dropping Dependents

Outside of the annual Open Enrollment period (which takes place each October 1-31 every year), 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 ORIGINAL DOCUMENTS - ONLY SEND COPIES

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