Health Plan Employee Enrollment Form

  • The employee enrolling in the plan must be actively working and paid for working 20 hours or more per week.
  • Except for address or beneficiary changes, Alliance Benefits must be notified within 30 days of a qualifying event (new hire, marriage, newborn, etc.) to enroll or make changes to your plan. If Alliance Benefits is not notified within the 30-day window, you must wait until the next open enrollment period to enroll or make changes to your plan.
  • The new enrollment effective date is the first day of the month following the qualifying event date. If the event date falls on the first day of the month, coverage will begin on this day.

Reason for Enrolling

Please select your reason for enrolling: *
 
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General Information

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Benefit Election

Medical Benefits: *
Coverage Type: *

Dependent Information

  List spouse and/or children to be covered (eligible children are those under the age of 26)
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Are you or any of your dependents (including spouse) covered under another health plan or Medicare?
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