Benefits Enrollment-Change Request Template
Employees not employed by the company on the Plan Effective Date must submit completed COM104-1 BENEFITS ENROLLMENT/CHANGE FORM to Personnel within 31 days from the employee’s first day of employment. If completed Benefits Enrollment-Change Request Templates are not received by the Personnel Department within 31 days, the employee and dependents may not be eligible to receive benefits under the plan until the next open enrollment period.
If an employee obtains a new dependent after the effective participation date became effective, the employee has 31 days to submit a revised enrollment form to Personnel in order for the new dependent to become a participant. A newborn child will be automatically covered for the first 31 days of life. However, if a Benefits Enrollment-Change Request Template is not properly submitted within 31 days of the birth, coverage will end after 31 days. An employee may opt to waive participation in the plan by submitting a written declination. Eligible employees may be eligible to receive compensation if participation is waived for the portion of the employee’s premiums that would have been paid by the company.
Benefits Enrollment-Change Request Template Details
Format: Microsoft Word 2013 (.docx)
Manual: Human Resources
Procedure: Healthcare Benefits Procedure COM104
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