ARBenefits Public School Enrollment Election Form
This form is to be used for Open Enrollment and New Enrollees ONLY. Please use the Change Form for Qualifying Events
Original Document
You are encouraged to review the original document prior to completing this form. Your answers will be embedded on the PDF form and submitted to the proper department.
Part 1: Employee Information
Name
First Name
Middle Initial
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Social Security Number
Agency
Home/Cell Phone Number
Work Phone Number
Street Address
City
State
Please Select
AR
OK
MO
ZipCode
Part 2: Coverage
Reason for Enrollment
Open Enrollment
New Hire Period
Qualifying Event
Type of Action
Enroll in the Plan
Decline Coverage
Add/Drop Dependent
Select a Benefit Option
Premium
Classic
Basic
Select a Coverage Level
Employee Only
Employee & Child(ren)
Employee & Spouse
Employee & Family
Please only check this box if you wish to have your premiums withheld on a post-tax basis.
Part 3: Add Dependents
Check the appropriate column to ADD eligible dependents not currently covered and/or DROP currently cover dependents. Proof of a dependent's eligibility must be submitted with this application for all dependents.
Dependents
Add
Drop
Name (First, MI, Last)
Date of Birth
Social Security Number
Male
Female
Relationship
1.
1. Spouse
2. Child
3. Perm Legal Guardianship
2.
1. Spouse
2. Child
3. Perm Legal Guardianship
3.
1. Spouse
2. Child
3. Perm Legal Guardianship
4.
1. Spouse
2. Child
3. Perm Legal Guardianship
5.
1. Spouse
2. Child
3. Perm Legal Guardianship
Part 4: Subscriber Certification
I authorize deductions of the required contributions (if applicable). I understand that my elections can only be changed during the next open enrollment period or if I have a qualifying status change event as defined in the ARBenefits Summary Plan Description. I understand I must request such changes within 60 days of the qualifying event. On behalf of myself and anyone enrolled on or added to this form, I authorize any health care professional or entity to give the health plan/insurer or any of their designees, any and all records or information pertaining to medical history or services rendered to the health plan/insurer the user of a Social Security Number for the purpose of identification. A photocopy of this authorization will be as valid as the original. Please not that falsifying documents, misrepresenting dependent status or using other fraudulent actions to gain coverage may be criminal acts and can lead to permanent termination of coverage. I understand by signing the election form, it means I have read and agree with the attached instruction page and understand the options I chose on the election form.
Signature
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Dependent Eligibility Proof - (if required)
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