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Insurance Paperwork

Insurance Information

*Required for all eligible staff (PT 30 or higher) *Turn in no later than 1 week after job change

  1. Must be filled out for all staff eligible for benefits

  2. Health Insurance enrollment for PT 30, FT 40 and FT 64 hr employees
    (Fill out Decline section if declining coverage)

  3. Dental/Vision/Life Insurance enrollment for FT 40 or FT 64
    (Fill out decline sections if declining coverage)

  4. Dental/Vision/Life Insurance enrollment for PT 30 hr staff
    (Fill out Decline sections if declining coverage)

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