Benefits & Human Resources


The Enrollment Form for Group Coverage is the application for the health, dental, term life, accidental death and dismemberment, and long-term disability coverages.

The employee completes section A, then the form is sent to the Office of Benefits/Human Resources; they will complete section B and forward the application as needed.

Forms can be obtained from James Clauson, Office of Benefits/Resources.
Instructions for the form are as follows:

1-6: This part’s pretty easy. Just fill in the required information.

7: Check the following boxes: Life (employee), LTD, AD&D.

  • If the employee wants health and/or dental insurance, check the appropriate boxes.
  • If the employee and/or dependents do not want health and/or dental insurance, be sure to complete section 16.

8 & 9: The answer to both is “standard”.

10: If the employee is electing health and/or dental insurance, fill in all the requested information except the primary care provider number. Our health plan does not require a primary care provider.

11,12, 13: Fill out these sections only if the employee is applying for health insurance.

14: This is where the employee designates beneficiaries for the term life insurance.

15: Sign in this area.

16. If the employee is waiving health and/or dental coverage for the employee and/or dependents, check the appropriate boxes and sign this section.

The completed form must be returned to the Office of Benefits/Human Resources within 30 days of the employee’s start date.

If the form is turned in within that time-frame, the coverage will start on the employee’s start date. If the form is not turned in on time you will have to wait until the next enrollment period or qualifying event.

James Clauson

Coordinator of Benefits