Page 1 - Opening Page - City/Town selection; Employee Name; Form Action

{citytown}  {group}

{employeeName}

Open Enrollment Review

You may experience a delay while the Benefits Administrator and Email fields populate.

As a retiree, you do not need to complete the waiver of medical coverage.  Please close this tab or webpage to exit.

As the spouse of a retiree who has elected to continue coverage under your own ID, you do not need to complete the waiver of medical coverage.  Please close this tab or webpage to exit.

If you are waiving medical coverage and need to make other changes to your benefits, please select "Change my benefits" from the drop-down menu.  You can still waive your medical coverage while changing other benefits.

This request has been {approval} and the record is locked.  If you believe it was approved or declined in error, please contact Nikki Willoughby for additional assistance.

{action866} - {employeeretireeName3}, {citytown}

{action866} - {employeeretireeName3}, {citytown}

Waiver of Medical/Prescription Coverage

• I am waiving medical coverage for myself and any eligible dependent.
• I understand that this waiver of coverage may affect the ability to obtain coverage at a later date.

Enrollment is automatic for Basic Term Life and AD&D paid 100% by your employer

{action866} - {employeeretireeName3}, {citytown}

Complete this portion of the page for any dependent you are adding to medical, dental, and/ or vision.  If enrolling your spouse, common-law spouse, or domestic partner add them as the first dependent.

           Relationship                       Dependent Name                Date of Birth                    Gender               SSN

Domestic Partners are allowed on the plan if the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form.

Common-Law spouses are allowed on the plan if the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form.

{action866} - {employeeretireeName3}, {citytown}

Available Benefits for 2025-2026 Plan Year

As a retiree (or enrolled as a retiree's spouse), if you have previously not enrolled or dropped a benefit for yourself, you are not eligible to re-enroll in that benefit.  You will be contacted if we determine an error in your open enrollment changes.

The {citytown} bundles benefits.  Please reset the benefits above to match the medical coverage level to proceed.

Waiver of Medical/Prescription Coverage

• I am waiving medical coverage for myself and any eligible dependent.
• I understand that this waiver of coverage may affect the ability to obtain coverage at a later date.

Enrollment is automatic for Basic Term Life and AD&D paid 100% by your employer

Voluntary Term Life is offered and premiums are paid entirely by the employee.

{action866} - {employeeretireeName3}, {citytown}

Voluntary Term Life & AD&D

The {citytown} offers Voluntary Term Life and AD&D coverage.  The employee pays this benefit 100%.  Additional details on this coverage can be found in the Voluntary Term Life and AD&D Summary. 

**Open Enrollment**: During open enrollment, an Evidence of Insurability (EOI) form is required if the employee's coverage increases more than $25,000, if the employee's coverage exceeds $350,000, if the spouse's coverage increases by any amount, and/or if the individual does not have Voluntary Term Life coverage currently and requests coverage.

Coverage Amount: The maximum amount an employee can apply for is 5x their salary up to the maximum of $500,000. Employees may purchase benefits increments of $5,000. Spouses may receive coverage, up to 100% of the employee amount, not to exceed $500,000.

Monthly Premium Rates per Thousand: Rates are age-banded for voluntary life and are shown below. AD&D rates are $0.05 per thousand for all ages. Volumes can be selected separately for voluntary life and AD&D coverage.

Dependent Child Benefit: Employees can cover their child(ren) in increments of $1,000, a minimum of $2,000 up to a maximum of $10,000. The cost is the same for one child or multiple children. The rate is $0.12 per $1,000 of coverage and employee coverage is required.  AD&D coverage is not available for children. Eligible children must be less than 26 years of age.

 

**If adding or changing this coverage you must complete the Voluntary Term Life Insurance Form and provide it to your benefits administrator to be submitted to MMIA upon approval of this request.

***ERROR*** The coverage you selected is greater than the coverage allowed based on your annual salary.  Please select an amount equal to or less than 5x your annual salary.

Voluntary Spouse benefits are only available if the employee elects the same coverage at an equal or greater value.

**ERROR**  You may not select a coverage amount for your spouse greater than your coverage.

Domestic Partners are allowed on the plan if the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form.

Common-Law spouses are allowed on the plan if the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form.

You have waived the voluntary life and AD&D coverage options.  You will not be enrolled in this benefit.  If you previously had coverage for yourself and any dependents, the benefit will be ended on June 30, 2025.

This is a summary of the benefits you have elected.  Once approved, you will receive a copy of these benefit selections via email if you provide an email address on the next page.

{action866} - {employeeretireeName3}, {citytown}

{whatIs}

City/Town-Paid Basic Term Life Insurance

{basicLife1019}        {basicDependent}

Employee-Paid Voluntary Term Life Insurance
{volLife}
	Voluntary Life	Voluntary AD&D
Employee	{vol}	{volAdampd}
Spouse	{volSpouse763}	{volSpouse764}
Dependent Child	{volDep771}

Use the "Back" button to return to the page where you need to make the correction.  Once complete, use the "Next" button to move forward through the form.

You may wish to submit an updated Beneficiary Form. If so, please provide the completed form to your benefits administrator.

*Your request requires a Domestic Partnership Affidavit.  Please provide the completed form to your benefits administrator.

*Your request requires a Common Law Affidavit.  Please provide the completed form to your benefits administrator.

*Your request requires a Voluntary Life Form.  Please provide the completed form to your benefits administrator.

 

Your request contains errors.  Please click the back button to correct the error.  You may wish to contact your benefits administrator if you are unable to complete the request.

Page 11 - Approval Page