ALLIANCE BENEFITS 2025 OPEN ENROLLMENT CHANGE FORM

Open Enrollment is October 28 - November 15, 2024. If you wish to make changes to your 2025 health plancoverage, please complete, sign, and

submit the inormation below by no later than November 15, 2024. All changes will be effective January 1, 2025.

Employee Information

Employer Name *

Employer Location or Church Code

Employees First Name *

Employee Last Name *

Date of Birth * +

SSN (last four digits) *

Home Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address *

County

Change in Current Benefit Election

Medical Benefits:

Employee Only

Employee + Spouse

Employee + Child(ren)

Family

Coverage Type:

Silver Plan Premium (Medical, HSA, Prescription, Dental, Vision, $30k Life Insurance, Long Term Disability)

Silver Plan Standard (Medical, HSA, Presccription, $30k Life Insurance)

Bronze Plan Premium (Medical, HSA, Prescription, Dental, Vision, $30k Life Insurance, Long Term Disability)

Bronze Plan Standard Plan (Medical, HSA, Prescription, $30k Life Insurance)

Add Dependents

(eligible children are those under the age of 26)

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

Remove Dependents

Dependent Full Name (First, MI, Last)

Birth Date +

Dependent Full Name (First, MI, Last)

Birth Date +

Employee Signature

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

clear

Signature Date * +