Open Enrollment Change Form

Open Enrollment is November 9-December 6, 2020. If you wish to make changes to your 2021 health plan coverage, please complete, sign, and submit the information below by December 4, 2020. All changes requested will be effective January 1, 2021.

Employee Information

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Change in Current Benefit Election

Medical Benefits:
Coverage Type:

Add Dependents

(eligible children are those under the age of 26)
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Remove Dependents

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Employee Signature

By signing, I authorize to be covered under the terms of the plan I have chosen. *
clear
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