https://www.in.gov/spd/2871.htm

For employees that do not currently have our insurance & wish to enroll, or employees that do not currently have our insurance and are waiving coverage for 2023.

*If you currently have our insurance, please use the single page change form, or continuation form.

Only use this form if you currently are on our health plan, & are keeping EVERYTHING the same with your health plan selection & dependents for 2023.

If you are making ANY changes, you must complete the Anthem Change Form instead.

For employees that currently carry our insurance, & are making changes to their existing plan (changing plan type, adding dependents, etc.) or are terminating coverage for 2023.  

MUST be completed for all employees enrolled in our health plan, regardless of whether you accept or decline to refrain from tobacco products. 

This form is only a confirmation of existing Guardian plan selections. Use this form if you are keeping everything the same as you are currently subscribed, for 2023, or if you have waived coverage previously & wish to do so again.

If you wish to change plans, drop coverage, etc, you MUST use the multi-page enrollment form.

*If you are unsure of your current plan, either cross reference the rate sheet against the premium being deducted from your payrolls, or simply write "NO CHANGES" on the form, & we will maintain your current set up.

Use this form to enroll in new coverage, add dependents to existing coverage, change your plan selection, or drop coverage.

*If you currently have coverage through Guardian & want to keep everything the same, please see the Benefit Plan Snapshot form.

*If you completed an initial waiver form for Guardian, and want to waive again, you may use the Benefit Plan Snapshot form.

Full plan information for our Dental & Vision Insurance options.