- DO submit a form if you are making changes, enrolling, or canceling coverage.
- DO sign and date your form and include your name, birthdate, Social Security number, and the information for any dependents you are enrolling.
- DO complete only the section(s) on the back of the form for coverage(s) you wish to change (health, dental, vision).
- DO submit your form prior to November 9, 2017. All changes made during open enrollment become effective January 1, 2018.
- DO NOT submit a form if you would like to continue with your current coverage.