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Benefits Election/Change Form Active Employees January 1, 2016 December 31, 2016 Check The Appropriate Box Initial Enrollment Open Enrollment Employment Status Change / / Special Enrollment / / Marriage / / Birth / Adoption / / Cancel

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4.7 out of 5

29 votes

The document is a Benefits Election/Change Form for active employees, covering the enrollment and changes in medical, dental, vision, and other insurance benefits for the year 2016. It includes sections for personal information, benefit elections, dependent coverage, flexible spending accounts, health savings accounts, and voluntary life insurance options. Employees can indicate their choices for coverage and must certify the accuracy of their information.

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Versions	Form popularity	Fillable & printable
2016	4.7 Satisfied (29 Votes)

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