ARBenefits Public School Enrollment Election Form

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.

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.

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.