2019 Enrollment / Change Form
Human Resources Use Only EMPLID:
New enrollment: Dental/Vision Effective Date: ___________________ PS Entered:
Change in coverage	Life/AD&D/STD/LTD Effective Date: _____________
a. reason for change:
b. date if change in status:
Termination date:	Part-time:
Employee Information (please print)
Last Name	First Name	Middle Initial
Employee #	Social Security #	Birthdate	Sex
Street Address	City	State	Zip
Marital Status/Date	Spouse name	Spouse birthdate	Phone number (home)
Benefits Selections
For each plan, check your selected options:
* 1. Dental	Coverage Level
PPO (Delta Dental of Washington) DMO (Delta Care-Delta Dental of Washington) DMO (Willamette Dental) No coverage	Participant only Participant and Spouse Participant and Child(ren) Participant, Spouse and Child(ren)
* 2. Vision	Coverage Level
Basic (VSP) Enhanced (VSP) No coverage	Participant only Participant and Spouse Participant and Child(ren) Participant, Spouse and Child(ren)
* 3. Term Life Insurance	Check the box for the total coverage requested; refer to rules located on SharePoint
You must at a minimum enroll in the first Employee option of $25,000.
Employee	Spouse: New hires can enroll their spouses in $12,500 or $25k with no EOI. Can’t exceed employee’s own amount.	Child(ren)
$25,000 Core
Supplemental (in addition to core) $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000 (No EOI required if enrolling as New Hire)	Supplemental $12,500 $25,000 EOI Required for below amounts $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 No coverage	$2,500 $5,000 $7,500 $10,000 No coverage
4. AD&D Insurance
Choose one option (cannot exceed $500,000 maximum plan limit)	Please Note: 1. Coverage must be in increments of $10,000. Family Coverage is calculated as a percentage of employee coverage.
Employee only Employee & family No coverage	Amount of Employee Coverage	$
5. Short-Term Disability
Cost is for employee-only coverage for up to 60 days. Pays 60% of employee’s salary (capped at $100,000 base salary).
7 day waiting period	30 day waiting period	No coverage
6. Long-Term Disability
Cost is for employee-only coverage after 60 days. 40% option is capped at $180,000 base salary; 60% option is capped at $200,000 base salary.
40%/60 day waiting period 60%/60 day waiting period	No Coverage
REMINDER: If you waive, or select a lower option, for Short and/or Long Term Disability, you cannot increase coverage without first obtaining approval from the carrier (via the Evidence of Insurability process)

* Paid on a pre-tax basis

Family Members to be Enrolled
SPOUSE	Last name	First name	Middle initial	Social Security Number
Street address (if different than employee)	City	State	Zip
Birth date	Sex	Relationship to you
CHILD	Last name	First name	Middle initial	Social Security Number
Street address (if different than employee)	City	State	Zip
Birth date	Sex	Relationship to you
CHILD	Last name	First name	Middle initial	Social Security Number
Street address (if different than employee)	City	State	Zip
Birth date	Sex	Relationship to you
CHILD	Last name	First name	Middle initial	Social Security Number
Street address (if different than employee)	City	State	Zip
Birth date	Sex	Relationship to you
Beneficiary Designation
Make your beneficiary designation for Term Life Insurance and AD & D Insurance (If trust or will listed – name of trustee or executor required)
PRIMARY	1. Last name	First name	Middle initial
Social Security Number	Date of Birth	% designation / Relationship
2. Last name	First name	Middle initial
Social Security Number	Date of Birth	% designation / Relationship
SECONDARY	1. Last name	First name	Middle initial
Social Security Number	Date of Birth	% designation / Relationship
2. Last name	First name	Middle initial
Social Security Number	Date of Birth	% designation / Relationship
Pre-tax Waiver (Optional)
Contact Human Resources if you would like to complete a pre-tax waiver to have your premiums deducted after taxes.
Employee Authorization
REQUIRED	I understand that I have made an election for my benefits package for the plan year. Any choices I have made may only be altered as the result of a change in family status as defined in the plan or if an IRS ruling affects the plan. I also understand that any unused amounts in either spending account will be forfeited after the end of the year. I agree to have my benefits contributions deducted from my pay on a before-tax basis (for specified before-tax benefits) unless I have signed the waiver box above. I authorize all health care providers, claim processing agents, insurance and reinsurance agencies or other persons or organizations performing direct administrative professional, medical, or legal services or care in connection with my claims to disclose any information necessary for investigation, evaluation, or payment of a claim. I understand that reasonable efforts will be made to use, disclose, and request only the minimum amount of information needed to accomplish the intended purpose of the use, disclosure, or request. I further verify that the information I have furnished is correct.
Employee Signature	Date