City Of Minneapolis - Health Plan Enrollment Change Form printable pdf download

City Of Minneapolis - Health Plan Enrollment Change Form

Instructions for Adding Dependents to Your Employee Benefits

To add a new dependent to your benefits coverage, you must complete the

following:

Health Plan Enrollment/Change Form. By completing this form you can

make changes to your medical coverage, dental coverage, and flexible

spending accounts. To add a dependent, you must provide copies of

marriage and/or birth certificates.

Optional/Dependent Group Term Life Enrollment Form. This form gives

you the option to do the following:

o If you already have optional insurance coverage and would like to

add dependent life insurance, you can enroll on this form.

o If you already have supplemental and dependent life insurance, you

can update the dependent/beneficiary section to reflect who is

covered under your dependent life insurance.

Beneficiary Designation Form. Complete this form if you would like to

update your beneficiaries for your basic life insurance or optional life

insurance.

Fax completed forms to 612-673-2533 or mail completed forms to:

City of Minneapolis, Human Resources-Benefits

250 S 4

Street - 100

Minneapolis MN 55415-1339

City Of Minneapolis - Health Plan Enrollment Change Form