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ACMEÂ CARE HOSPITAL
123 Maple Street Anytown, PA 17101
info@example.com
www.example.com
(123) 1234567
Benefits Open Enrollment Form
Employee Name
First Name
Last Name
Employee ID Number
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Request
New Hire
Newly Eligible
Rehire
Beneficiary Update
Qualified Life Event (QLE)
Other
Date of QLE
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Enroll / Add
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Employee
Change in legal marital status
Loss of eligibility or other coverage
Returns from unpaid leave
Moves into plan service area
Other
Spouse
Change in legal marital status
Loss of eligibility or other coverage
Moves into plan service area
Other
Children
Birth
Adoption
Foster Care
Legal Guardianship
Loss of Eligibility or Other Coverage
Moves into Plan Service Area
Qualified Medical Child Support Order
Other
Remove
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Employee
Change in legal marital status
Gains other coverage
Begins unpaid leave
Moves from plan service area
Death
Other
Spouse
Change in Legal Marital Status
Gains Other Coverage
Dissolves Domestic Partnership
Moves From Plan Area
Death
Other
Child(ren)
Reaches Age 26
Gains Other Coverage
Dissolves Domestic Partnership
Moves From Plan Service Area
Death
Other
Miscellaneous
Cancel Dependent Life
Cancel Short Term Disability
Change in Day Care Expense or Provider
Non-payment of Premiums During Leave
Eligible for LTD Benefits
Other
Dependents
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Please list all the dependents and select plans for them.
Health Plans
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Medical Plans
Enroll
Decline / Cancel
Change
No Change
EPO Provider Networks
Aetna
CIGNA
United Health Care
EPO Coverage Level
Employee
Employee+Adult
Employee + Child
Employee+Family
PPO Provider Networks
Aetna
CIGNA
United Health Care
PPO Coverage Level
Employee
Employee+Adult
Employee + Child
Employee+Family
Aetna HSA Option
Employee
Employee+Adult
Employee + Child
Employee+Family
Dental Plans
Â
Delta Dental
Employee
Employee+1
Employee+Family
Other
Total Dental Administrators
Employee
Employee+1
Employee+Family
Other
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: