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2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE-2026
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- Click ‘Get Form’ to open the 2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE in the editor.
- Begin by filling out your personal information in the EMPLOYEE INFORMATION section. Include your first name, last name, address, birth date, and contact details.
- 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.
- Next, complete the DENTAL INSURANCE SELECTION section by choosing your preferred plan and providing any necessary Primary Care Dentist information.
- Fill out the VISION INSURANCE SELECTION section similarly, selecting your coverage option and providing reasons for declining if applicable.
- List any dependents under DEPENDENTS TO BE PLACED ON MEDICAL, DENTAL, OR VISION PLANS. Ensure all required fields are filled accurately.
- Finally, complete the BENEFICIARY DESIGNATION section carefully and sign the form to authorize payroll deductions.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4 Satisfied (60 Votes) |
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Related links
Can I do this anytime throughout the year? No, you have until the deadline of June 3, 2015 to complete the enrollment process for 2015-2016.Read more
Feb 27, 2015 For matters related to re-enrollment, open enrollment periods, or exemptions from the individual shared responsibility payment: Christine.Read more
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