Below you will find the documents and directions that you need to complete your enrollment for 2018.
Please follow the instructions carefully! You may call us at any time if you have any questions: (818) 546-8415.
If you are NOT changing your plan type (PPO or HMO), you do NOT need to complete any other forms, with one exception: FSA and HSA Contributions. A new form is required each calendar year. You will remain in your current plan type (PPO or HMO) unless you submit completed and signed change forms.
If your spouse is not eligible to be covered but wishes to buy in to our plan, you must complete the Spouse application form (for your spouse buy-in participants). Please contact Human Resources for the appropriate form to report these changes.
If you want to switch plans, or if you are enrolling for the first time, please contact the office for information and the forms: firstname.lastname@example.org.
If you are opting out, you must contact HR for the forms.
- Change Notification Form (This form is necessary to report any changes in marital status, dependent status, or address changes.)
- Wage Works Flexible Spending Account (FSA) Form (For those on HMO for healthcare or those who have dependent day care. $5000 max dependent day care and $2600 max health care).
- HSA Contribution Form (For those on the PPO Plan, contributing your own funds to the Optum Bank Health Savings Account.)