Active Enrollment Change Form-Loss of Coverage/Job (Required documents & steps)

This is a document designed for active employees who have life-events and need to make changes to the enrollments. 

Life Event Type and Required Documentation

Loss of Coverage/Job:

-Separation notice, documentation showing when coverage ends

Steps to Start Life Event Process 

1. Please complete the enrollment change form listed below and submit the form along with the above document to the Benefits Department via the [e-mail] email address.

-Enrollment Change Form-

https://na3.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=0c0bf311-c02b-4cb1-acba-3a37930c6388&env=na3&acct=19cbdccc-227e-46af-a46c-0559a3cca114&v=2m