Open Enrollment

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• 2009
• 2010

2009 Employee

• Amendment to Original Application (Nonsmoker Certification) (50.5 KB)
• Employee Enrollment/Change (435.8 KB)
• Employee Enrollment/Change for Medical Only Groups (402.2 KB)
• Life Insurance Change Form (179.6 KB)
• Life Insurance Enrollment Form (139.5 KB)
• Life Insurance Evidence of Insurability (97.8 KB)
• Long Term Disability Enrollment/Change Form (109.3 KB)
• Long Term Disability Evidence of Insurability (101 KB)
• Section 125 Waiver Form (122.4 KB)

2009 Retiree

• Medicare Advantage Disenrollment (Form D) (302.2 KB)
• Medicare Advantage Enrollment (Form C) (392.1 KB)
• Medicare Supplement Enrollment (Form B) (275.6 KB)
• Retiree Coverage Election Form (Form A)--enrollment for new retirees, and account changes for existing retirees (499.6 KB)

2009 Dependent Certification

• 2009 Adult Dependent Enrollment/Change (345.8 KB)
• Dependents with Disabilities (311.4 KB)
• Extended (Legal) Dependents (243.5 KB)
• Spouse or Qualified Domestic Partner Certification (447.9 KB)
• Student Certification/Change (234.3 KB)

2009 Continuation of Coverage

• COBRA Continuation of Coverage (456 KB)
• Leave Without Pay (492.6 KB)
• Life Conversion Information Request (505 KB)
• Participant's Notice of Other Health Coverage (for reduced-premium COBRA members only) (54.2 KB)
• Uniform Medical Conversion Plan Enrollment Form (241.2 KB)

2009 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)