Open Enrollment

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• 2009
• 2010

2010 Employee

• Employee Enrollment/Change (457.7 KB)
• Employee Enrollment/Change for Medical Only Groups (449.9 KB)
• Life Insurance Change Form (130.1 KB)
• Life Insurance Enrollment Form (68.7 KB)
• Life Insurance Evidence of Insurability (80.5 KB)
• Section 125 Waiver Form (122.4 KB)

2010 Retiree

• Medicare Advantage Disenrollment (Form D) (312.1 KB)
• Medicare Advantage Enrollment (Form C) (448.4 KB)
• Medicare Supplement Enrollment (Form B) (287.4 KB)
• Retiree Coverage Election Form for Open Enrollment (Form A) (511.5 KB)

2010 Dependent Certification

• Adult Dependent Enrollment/Change (395 KB)
• Dependents with Disabilities (345.9 KB)
• Determining Dependent Tax Status (includes Declaration of Tax Status Form) (332.1 KB)
• Extended (Legal) Dependents (413.3 KB)
• Student Certification/Change (224 KB)

2010 Continuation of Coverage

• COBRA Continuation of Coverage Election (724 KB)
• Leave Without Pay (538.9 KB)
• Participant's Notice of Other Health Coverage (for reduced-premium COBRA members only) (54.2 KB)

2010 Miscellaneous

• Authorization for Release of Information (146 KB)
• Change in Beneficiary (Employees: Submit to your payroll office) (62.3 KB)
• Electronic Debit Service Agreement (352.7 KB)
• Notice of Appeal (267.7 KB)
• Request for Review (269.5 KB)
• Request to Cancel Dependent Coverage (159.5 KB)