Health Benefits Enrollment Form - (Medical Benefits worksheet)

Please complete all circled areas of the form and turn in to Human Resources. For changes to your health benefits, please list all people you wish to cover on your plan, including yourself. If you are adding dependents, a marriage certificate, domestic partner certification or birth certificate is required as applicable. If you are deleting dependents, a letter indicating other coverage or a divorce decree is required as applicable. Social security #'s for dependents are required.