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Benefits Enrollment Form

The below information is your information, as the employee.
Please fill out all the information below.
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New Hire
Date is the first day of the third pay period following two full pay periods worked.

Marriage, domestic partnership affidavits, divorce, cessation of domestic partnership.
Date is the day the event occurs.
Divorce should be the date the final decree is filed (this sometimes is different than the date the documents were signed by the courts).

Birth of a child.
Date is the day the event occurs.
A newborn can be added on to benefits with the hospital proof of birth; however, if the employee does not submit an official birth certificate within 60 days of the date of birth, the baby will be retro-termed and the employee will be responsible to pay all incurred baby-related expenses and claims. The result: because the baby was never covered (due to the retro-term), the baby is NOT eligible for COBRA. At future Open/Switch Enrollments, the baby can be added if an official birth certificate is provided.

Change in job status (Part-Time to Full-Time or Full-Time to Part-Time)
Promotions and transfers are not eligible to change benefit elections.
Date is the day following the event.
Termination is handled automatic by the Job Data entry and HR sends a COBRA Notification to ERISA- no need for an enrollment

Gain of other coverage
Date is the day prior to the new coverage effective date.
Proof of gain of coverage is required. Must be faxed to Erisa (505) 244-6009) within 31 days of the event.

Loss of other coverage
Date is the day after the date of loss of coverage.

Death of dependent
Date is the day reflected on Death Certificate.
Death of employee – no form is needed (system auto term’s employee and dependent(s) benefits – Cobra Notification is sent to Erisa via HR for surviving dependents; if applicable

Reinstatement by approval.
Contact Risk Management Division Employee Benefits Bureau for reinstatement of employment benefits.

Open/Switch Enrollment
January 1st, 2016.


Taxpayer ID *  
Gender *  
Marital Status *  


Preferred Phone Number *   

Security Code *

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