Benefits Open Enrollment Missed Deadline Appeal Form
Use this form to request review of a missed benefits open enrollment deadline and explain the circumstances for your appeal.
Employee Information
Employee Name
*
First Name
Middle Name
Last Name
Employee ID
Department
*
Please Select
Human Resources
Finance
Information Technology
Operations
Sales
Marketing
Customer Service
Other
Job Title
*
Work Location
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Enrollment Missed Deadline Details
Benefits Enrollment Year / Plan Year
*
Date You Realized the Deadline Was Missed
*
-
Month
-
Day
Year
Date
Date Enrollment Should Have Been Completed By
*
-
Month
-
Day
Year
Date
Did You Previously Enroll or Attempt to Enroll?
*
Yes, I enrolled previously
Yes, I attempted to enroll
No
Other
Briefly Explain How the Deadline Was Missed
*
Appeal Request and Supporting Information
Reason for Missing the Deadline
*
Please Select
Medical emergency
Family emergency
Administrative error
Unaware of deadline
Other
Requested Benefits Change or Enrollment Action
*
Please Select
Enroll in benefits
Add dependent
Change coverage level
Terminate coverage
Make another permitted change
Supporting Documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Appeal Statement
*
Acknowledge Information Accuracy
*
I confirm the information provided in this appeal is accurate and complete for review purposes only.
Submit Appeal
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