Open enrollment form 2026

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The document is an Open Enrollment Form for the Christian Brothers Employee Benefit Trust, requiring employees to provide personal information and select their desired benefits during a specified enrollment period. It includes sections for employee details, benefit elections or waivers, and authorization to release medical information. Employees must complete the form within 60 days before the effective date and certify the accuracy of their information.

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Click ‘Get Form’ to open the open enrollment form in the editor.
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.
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.
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.
If you choose to waive medical coverage, check the appropriate box and provide a reason for declining coverage.
Fill out the Other Coverage/Authorization To Release Information section as required. Make sure to certify that all information provided is complete and true.
Finally, sign and date the form before submitting it through our platform for processing.

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Versions	Form popularity	Fillable & printable
2017	4.2 Satisfied (53 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the intent to enroll form?

Definition(s) Intent to Enroll - Online submission used by applicant to notify the University of their acceptance of the offer of admission and intention to enroll for the term which they have applied.

What is the open enrollment law in Missouri?

SB 1051 - This act establishes the Public School Open Enrollment Act to enable students to transfer from their district of residence (resident district) to a nonresident district. The Act shall become effective on July 1, 2025.

What is the meaning of enrollment documents?

Enrollment Documents means all of the forms in the enrollment packet provided to you by ACT that are applicable to your situation.

What is the meaning of open enrollment?

: a period of time during which you can join something as a member or participant : a period of time during which you can enroll in something. Employees can sign up for new benefits during open enrollment. an open enrollment period.

What is an enrollment form?

Enrolment Form means the document signed and submitted by an applicant to apply for membership in [club]. Seen in 2 SEC Filings. Enrolment Form means the form developed from time to time by [organization] for the purpose of enrolling an eligible participant in a [plan].

christian brother services

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What is the purpose of an enrollment fee?

Enrollment fee means the fee a school charges that covers those expenses incurred by a school in processing the student enrollment agreement and establishing a student records system.

What is the purpose of an enrollment form?

An enrollment form is a type of form used to collect information from individuals who are registering for a service, program, or event. The purpose of an enrollment form is to gather the necessary data to enroll the individual and ensure that they meet the eligibility criteria for the service or program.

What qualifies you for open enrollment?

If you get health insurance through your job, through Medicare or through the Affordable Care Act (ACA) marketplace, you will have an open enrollment period.