To make a change from your existing coverage to another plan, enroll or cancel coverage for yourself or any of your dependents, or to enroll with the town as a new subscriber please complete the Insurance Company's Application/Enrollment Form, found below.
If the change you are making results in a corresponding change to your premium (new, increase or decrease) you also need to complete an Employee Payroll Agreement, found below.
If you are enrolling a dependent for the first time you must include:
For a spouse or ex-spouse: a copy of their Social Security Card and your city/town issued marriage certificate or your divorce decree.
For dependent children under age 26: a copy of their Social Security Card and a birth certificate, adoption or guardianship papers.
All applications and accompanying paperwork must be received by the Benefits Coordinator in the Town Manager's Office, within 30 days of the qualifying event.
Please contact the Benefits Coordinator at firstname.lastname@example.org to determine what additional documentation is required.