Benefit Forms for Open Enrollment 2013

You do not need to complete an enrollment form if you are not making changes this year EXCEPT for re-enrollment in either the healthcare or dependent care flexible spending accounts.

If you are making a change this year, you are asked to provide your instructions on the electronic "Change Form" available at the link below.  You will find that the electronic Change Form, which is a Microsoft Excel workbook, calculates rates for each available option that you select.  Note that the form includes 4 separate tabs that you will want to complete or review.  You can navigate between tabs by clicking on the tab labels toward the bottom of your screen.  Once you are satisfied with your selections,  please print each page and sign where indicated.  Return your printed and signed form to Ruth Sanoy, Office of Human Resources.  Be sure to keep a copy for your records! 

Also, check your January 2013 pay advice, or contact the appropriate benefit plan provider after the first of the year,  to confirm that your requested changes have been made.

 > 2013 Benefits Enrollment Form  (Microsoft Excel file) -  to add, change or stop coverage for any of these plans in 2013:
 

> Cigna Beneficiary Designation Form
> Cigna Evidence of Insurability Form - for life insurance if requesting coverage exceeding $200,000 or $20,000 for a spouse/LDA.