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 to, for 2024, 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 payroll, or simply write "NO CHANGES" on the upper right corner of the form, & we will maintain your current set up.