OPPJ Employee Open Enrollment Newsletter

FLU SHOT AUTHORIZATION FORM - Complete and bring to Open Enrollment with your Health Insurance Card

Insurance Forms

HEALTH
BCBS Health Enrollment and Change Form - To ADD/CHANGE Health Coverage
** TO ADD Health Coverage, also complete the FLEXIBLE BENEFITS FORM
(Only 1 Flexible Benefits Form is needed for all insurance additions and cancelation)

BCBS Health Cancellation Form - To DROP Health Coverage
** TO DROP Health Coverage, also complete the FLEXIBLE BENEFITS FORM


DENTAL
MetLife Dental Enrollment and Change Form - To ADD/CHANGE Dental Coverage
** TO ADD Dental Coverage, also complete the FLEXIBLE BENEFITS FORM

MetLife Dental Cancellation Form - To DROP Dental Coverage
** TO DROP Dental Coverage, also complete the FLEXIBLE BENEFITS FORM


VISION
GUARDIAN Vision Enrollment and Change Form - To ADD/CHANGE Vision Coverage
** TO ADD Vision Coverage, also complete the FLEXIBLE BENEFITS FORM

Guardian Vision Cancellation Form - To DROP Vision Coverage
** TO DROP Vision Coverage, also complete the FLEXIBLE BENEFITS FORM


FSA
FLEXIBLE SPENDING ACCOUNT
** TO ADD the Flexible Spending Account for 2022,
also complete the FLEXIBLE BENEFITS FORM


FSA Information Packet


VOLUNTARY LIFE
MetLife VOLUNTARY LIFE INSURANCE - To ADD or INCREASE
**Statement of Health Form must be completed with any Voluntary Life Adding coverage or Increasing coverage for EACH Individual Coverage is requested
(For Example: Employee, Spouse, and 1 Child adding/increasing coverage - 3 Statement of Health forms must be completed)

BASIC and VOLUNTARY LIFE Beneficiary Change Form



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