Benefits Open Enrollment 2018
PLEASE CHECK A BOX IN EACH OF THE 3 SECTIONS BELOW AND SUBMIT
Email address *
Medical Insurance *
Medical Insurance Details: Separate enrollment form is required if dropping or adding coverage, changing plans, or changing who is covered. In the space below, tell us what you want to change.
Your answer
Dental Insurance *
Dental Insurance Details: Separate enrollment form is required if dropping or adding coverage, changing plans, or changing who is covered. In the space below, tell us what you want to change.
Your answer
Flexible Spending Account (FSA): an election form must be submitted if electing an FSA for 2018-19 (you MUST enroll each year). *
Required
Flexible Spending Account Details: Separate enrollment form is required by 3/2/2018 if you are electing this year. Note: You must be an active participant (make an election) if you want to use roll-over funds from the previous year. Use the space below if you have any comments.
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