• Open Enrollment Request Form

    Effective
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  • DEPENDENT INFORMATION

  • If you are enrolling your spouse, ALL fields must be completed below:

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  • If you are enrolling your child(ren), ALL fields must be completed below:

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  • ADD LINK TO BENEFIT SUMMARIES HERE

  • EE bi-weekly cost Employee  EE + Spouse  EE + Child(ren) Family
    UHC Buy Up Plan 2000 $ 140.23 $ 339.35 $ 253.25 $ 467.17
    UHC Base Plan 5000 $ 123.31 $ 298.42 $ 222.71 $ 410.82

  • ONLY complete the dental and vision selections if you wish to make changes

  • EE Bi-Weekly Cost Employee Employee + Family
    DENTAL PLAN $ 10.90 $ 38.40
  • EE bi-weekly cost Employee Family
    VISION PLAN $ 2.56 $ 7.07

  • Principal Life Insurance and Disability Benefits

    If you wish to enroll in the Principal Life and/or Disability benefit options, please review the summaries here: Principal Benefit Summaries

    These enrollments will exclusively be captured on the below enrollment and beneficiary designation forms. Please print, complete, and upload only if you wish to enroll in Life or Disability benefits.

     

    If you do not wish to make any changes to your Life/Disability benefits, you do not need to complete these forms. No changes will be made.

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