Open enrollment form 2026

1. Click ‘Get Form’ to open the open enrollment form in the editor.
2. Begin by filling out the Employee Information section. Enter your Location Name, Location Number, Last Name, First Name, Home Address, City, State, Social Security Number, Date of Birth, Home/Cell Phone, E-mail Address, and select your gender and marital status.
3. In the Benefit Election(s) or Waiver of Medical Coverage section, indicate who will be covered (yourself, spouse, children) and select the type of coverage you wish to enroll in for each dependent.
4. Complete the Dependent Information section by listing each dependent's name along with their Social Security Number and Birthdate. Ensure that all information is accurate.
5. If you choose to waive medical coverage, check the appropriate box and provide a reason for declining coverage.
6. Fill out the Other Coverage/Authorization To Release Information section as required. Make sure to certify that all information provided is complete and true.
7. Finally, sign and date the form before submitting it through our platform for processing.

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