2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE-2026

1. Click ‘Get Form’ to open the 2015-2016 OPEN ENROLLMENT ELECTION FORM EMPLOYEE in the editor.
2. Begin by filling out your personal information in the EMPLOYEE INFORMATION section. Include your first name, last name, address, birth date, and contact details.
3. 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.
4. Proceed to the HEALTH SAVINGS ACCOUNT section if applicable. Indicate how much you wish to contribute per pay period.
5. Next, complete the DENTAL INSURANCE SELECTION section by choosing your preferred plan and providing any necessary Primary Care Dentist information.
6. Fill out the VISION INSURANCE SELECTION section similarly, selecting your coverage option and providing reasons for declining if applicable.
7. List any dependents under DEPENDENTS TO BE PLACED ON MEDICAL, DENTAL, OR VISION PLANS. Ensure all required fields are filled accurately.
8. Finally, complete the BENEFICIARY DESIGNATION section carefully and sign the form to authorize payroll deductions.

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