Open Enrollment Extension Request Form
Submit your request to extend the open enrollment period. Please provide accurate information and supporting documentation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Enrollment
*
Please Select
Health Insurance
Dental Insurance
Vision Insurance
Retirement Plan
Academic Program
Other
Current Enrollment Deadline
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Extension Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Extension Request
*
Have you previously requested an extension for this enrollment period?
*
Yes
No
Supporting Documentation (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Method of Contact
*
Email
Phone
Either
Additional Comments (optional)
Submit Request
Should be Empty: