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Anthem Customer Service 1.844.402.53472022 DENTAL INSURANCE ENROLLMENT/CHANGE FORM Section 1: To Be Completed by IC/HRG KHRIS Personnel Number Date of Hire Effective Date Organizational Unit # Cost
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How to fill out 2022 benefits enrollment change

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How to fill out 2022 benefits enrollment change

01
Review the list of available benefits for the upcoming year.
02
Consider any changes in your personal or family situation that may affect your benefit needs.
03
Complete the enrollment change form with accurate information.
04
Submit the form by the deadline provided by your employer.
05
Keep a copy of the completed form for your records.

Who needs 2022 benefits enrollment change?

01
Employees who want to make changes to their benefits for the upcoming year.
02
Employees who have experienced a qualifying life event that allows them to make changes to their benefits.

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The benefits enrollment change form is a document that allows employees to update their benefits selections, such as adding or removing dependents, changing coverage levels, or switching plans due to qualifying events.
Employees who experience a qualifying life event, such as marriage, divorce, birth of a child, or loss of other health coverage, are required to file a benefits enrollment change form.
To fill out the benefits enrollment change form, an employee should provide their personal information, details of the change being requested, and any supporting documentation needed to verify the qualifying event.
The purpose of the benefits enrollment change form is to formally request changes to an employee's benefits package during specific enrollment periods or following qualifying life events.
The information that must be reported includes the employee's personal details, the specific changes being requested (e.g., adding dependents, changing plans), and any necessary documentation for verification.
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