Health Plan Change Form

  • 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 a 30-day window, you must wait until the next open enrollment period to enroll or make changes to your plan.
  • Approved changes will be effective on the first day of the month following the qualifying date (except for births or deaths which will be effective on the actual event day). If the change occurs on the first day of the month, this will be the effective date.
  • Voluntary Life Insurance changes may be possible with certain qualifying events. In the absence of a qualifying event, any changes must be first approved and may require evidence of insurability.

Requested Change Type

Note: There must be a qualifying event to add a dependent such as marriage, birth, etc.) *
 
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General Information

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Add Dependents

(eligible children are those under the age of 26)
Qualifying event:
 
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Are you or any of your dependents (including spouse) covered under another health plan or Medicare?
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