2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE-2025

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The document is a 2015-2016 Open Enrollment Election Form for employees, detailing options for medical, dental, and vision insurance selections, as well as contributions to a Health Savings Account. It includes sections for personal information, coverage elections with associated costs, primary care provider designations, and beneficiary designations for life insurance. Employees must sign and date the form to authorize payroll deductions and confirm their understanding of the enrollment process.

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Click ‘Get Form’ to open the 2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE in the editor.
Begin by filling out the EMPLOYEE INFORMATION section. Enter your first name, last name, address, birth date, and contact details. Ensure all information is accurate for proper processing.
In the MEDICAL INSURANCE SELECTION section, select your desired coverage option. Review the monthly deductions and choose accordingly. If opting for a BlueCare HMO plan, provide your Primary Care Physician's details.
Proceed to the HEALTH SAVINGS ACCOUNT section if applicable. Indicate how much you wish to contribute per pay period.
Fill out the DENTAL INSURANCE SELECTION section by choosing your preferred plan and providing necessary details about your Primary Care Dentist if required.
Complete the VISION INSURANCE SELECTION section similarly by selecting an option and providing any necessary information.
List any dependents under DEPENDENTS TO BE PLACED ON MEDICAL, DENTAL, OR VISION PLANS. Ensure all fields are filled accurately.
Finally, complete the BENEFICIARY DESIGNATION section clearly indicating primary and contingent beneficiaries before signing and dating the form.

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