Enroll Online

Enroll Online

There are three (3) Open Enrollment forms available for online submission. Please read the descriptions for each form and click on the appropriate one. Complete and submit the form by November 22, 2019. Submissions after November 22, 2019 will not be accepted.

  • 2020 Open Enrollment Form:
    This form should be used by any member whose employer contributes on an Hourly rate or Flat Rate each month. Members can use this form to indicate which Plan Level they would like to select for an effective date of January 1, 2020.
  • 2020 Composite Rate Enrollment Form:
    This form should be used by any member whose employer contributes the Composite Rate each month. For Composite members, Family coverage is automatically provided. Members will use this form to indicate which dependents they would like covered under their Plan.
  • 2020 COBRA Enrollment Form:
    This form is used to indicate which dependents a member on COBRA would like covered under their Plan.