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  • Enrollment Information Form

  • Get Started!

    The information you need to provide to the Benefits Administrative Office includes your current medical coverage insurance plan name, your premium amount, tax subsidy amount, and the start date of your coverage for that premium amount. You can get this information from your insurance carrier or your Health Insurance Marketplace. Note: Once you submit this information and it is received by the Benefits Administrative Office, it can take up to 20 business days to see that information reflected on your Benefit Convenience Card.

    IMPORTANT: If you have not already done so, please fill out the annual pre-enrollment paperwork (HIPAA, Statement of Understanding, Agent of Record and Consent forms) for your area:

    • 2021 Annual Paperwork
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  • Personal Information

    Use this form after you have updated your information with the Health Insurance Marketplace to inform the Benefits Administrative Office of potential changes to your medical premium information or changes in your medical coverage. This information will be used to update your information and benefits in the system. PLEASE NOTE: This form should be completed after you enroll in a Marketplace plan. Completing this form does not enroll you in coverage or benefits.

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  • Insurance Information

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  • Premium Information

    You will get a bill from your insurance carrier once your enrollment or re-enrollment information is processed. The Benefits Administrative Office will need to know your monthly premium information to update the benefits on your Benefit Convenience Card.

    You should be able to find most of the following information in a letter from your insurance carrier or in your healthcare.gov account. 

  • Family Information

    You will be reimbursed only for your portion of the premium, and not the cost for family coverage. Please fill out the information below to alert the Benefits Adminstrative Office if you have multiple people enrolled on your insurance plan.

  • Form Terms

  • Should be Empty: