2026 Composite Rate Plan Form Logo

  • 2026 Composite Rate

    Open Enrollment Form

  • Important Notice

    Open Enrollment period (October 20, 2025 – November 22, 2025) provides you with an opportunity to add or drop eligible dependents, for coverage effective January 1, 2026, under the Alaska Teamster-Employer Welfare Plan. Late enrollments will not be accepted.

    If you do not wish to make changes during this Open Enrollment period, your dependents will default automatically to those dependents you currently have enrolled in the Plan, and unless you qualify for Special Enrollment your next opportunity to change your coverage designation will be during the next annual Open Enrollment period.

    All enrollments and/or changes requested herein are subject to the specific terms and conditions described in the Plan’s Summary Plan Description Booklet.

  • Personal Information

  •  - -

  • Plan Information

  • Please note: Composite Rate members have automatic Family Plan Level Coverage

    Family Plan Level: The Family Plan Level provides medical, dental, prescription drug and vision benefits to the Eligible Employee, their eligible spouse, and their eligible dependent children.

    Cost: $2,487.00 per month

  • Dependent Information

    Add up to four dependents (including spouse) below. If you do not have any dependents to add, select No. If you would like to remove dependents, click Yes and select NEXT. If you do not have any dependents to remove, click No.

  • Note: The following documentation/information is required if you are adding a spouse and/or dependent(s) in the event it has not been previously submitted:

    (1) a marriage certificate if you are married, (2) birth certificates for your dependent children (including eligible adopted children, step children, and foster children) as well as (3) any applicable legal documentation (e.g. adoption/foster child papers and/or child custody/support documents), (4) Social Security Number - dependents will not be enrolled if a valid SSN is not provided.

  • Spouse

    Skip by selecting NEXT if you are not adding a spouse.
  •  - -

  • Dependent 1

    Skip by selecting NEXT if you are not adding a dependent.
  •  - -

  • Dependent 2

    Skip by selecting NEXT if you are not adding a second dependent.
  •  - -

  • Dependent 3

    Skip by selecting NEXT if you are not adding a third dependent.
  •  - -

  • Supporting Documents

    Upload the supporting documents for each dependent or spouse.

  • Note: The following documentation/information is required if you are adding a spouse and/or dependent(s) in the event it has not been previously submitted:

    (1) a marriage certificate if you are married, (2) birth certificates for your dependent children (including eligible adopted children, step children, and foster children) as well as (3) any applicable legal documentation (e.g. adoption/foster child papers and/or child custody/support documents).

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Other Insurance

    For the purpose of Coordination of Benefits, please provide other insurance information that you or your covered dependents have in the space below. If you do not have other insurance, skip by selecting NEXT.

  • COBRA

  • Signature

    I understand the election I have made for Plan Level coverage will be effective January 1, 2026 provided that I am then eligible under the Plan by (1) active employment eligibility, (2) Dollar Bank reserve eligibility, or (3) COBRA eligibility and I have provided the required information and documents. I further understand that if the Plan Level coverage I have elected requires a contribution towards the cost of the Plan coverage, I hereby authorize that a self-payment deduction be commenced in the appropriate amount.
  • Powered by Jotform SignClear
  •  - -

  • WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
    Did you know that your Plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema)? Call your Plan Administrator at (907) 751-9700 or you may dial (800) 478-4450 (toll-free) for more information.

     

    FRAUD WARNING
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

  • Should be Empty: