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Benefits Enrollment

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

No Change

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.

Disability Coverage.
Effective date must be the start of the next pay period.
Disability is a non-contributory benefit. Employee pays 100% of the premium.
Note: You must pay in to the benefits for twelve consecutive months before being able to use the benefit.

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.

2024 Open Enrollment
Benefit changes will take effect 01/01/2024


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Gender *
Marital Status *
 of physical residence*

Preferred Phone Number * 

Any person who knowingly and with intent to defraud any insurance company or other person files a statement containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime, Insurance Fraud will be prosecuted to the fullest extent of the law and will prohibit access to RMD Benefits in the future.

I have had the opportunity to ask questions about my benefit options and my enrollment elections reflect my informed decisions.

I understand that once I submit my enrollment information, including any waiver, I will have limited opportunities to change my enrollment elections other than during the open/switch enrollment in the fall of each year for benefit plan years starting each January 1st.

I reviewed the information I provided in this enrollment before submitting and I confirm that the information accurately reflects my elections.

I acknowledge that is my responsibility to notify the provider, at the time of visit, that the care being received is due to a third party.

I authorize premium deductions to be taken from my salary per NMSA § 10-7-5 to pay for the benefits I have elected. I understand those deductions shall be taken from my earnings on a pre-tax basis unless I submit the required POP waiver form.

I understand that services will be available subject to exclusions, limitations, and conditions described in the summary plan descriptions (found on each carrier’s website). I authorize any hospital, physician, dentist, or other health care provider to furnish, medical information regarding me and my dependents necessary to process claims. I authorize the carrier to coordinate benefits and/or reimbursements with other health or dental plans or insurance companies. I certify that the above information is correct to the best of my knowledge and belief.

The State’s Group Benefits Plan is required by Federal Law to maintain and protect the privacy of your health information and provide you with notice of its legal duties and privacy practices. The privacy notice is posted at on the website. If you have any questions regarding this notice or the privacy of your health information, please contact RMD at PO Box 6850, Santa Fe, NM 87502, or by telephone at 505-827-2036.

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