Enrollment change application state plan - Middle Tennessee 2025

1. Click ‘Get Form’ to open the Enrollment change application in the editor.
2. Begin with Part 1, where you will check all applicable boxes for enrollment or changes. Ensure to include the effective date, which must be the first of the month.
3. In Part 2, complete your personal information including your last name, first name, SSN, and date of birth. If your spouse is also a state employee, provide their details as well.
4. Move to Part 3 to list any dependents. Fill in their names, social security numbers, birthdates, and relationships. Remember to attach additional sheets if necessary.
5. In Part 4, select your desired health and dental coverage options. Make sure to indicate whether you are opting for single or family coverage.
6. Complete Part 5 by designating a beneficiary for basic life coverage if applicable.
7. Finally, review and sign Part 6 to confirm that all information is accurate before submitting the form.

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