Events Available:

• Begin / Continue Event
• Reset and Begin Event
• Cancel Event

Instructions

Now that you have selected an event from your homepage, you will be required to complete a series of steps. These steps are identified as tabs above. As you move through each step, the tab will become enabled for each step that you have either begun or completed. You can revisit any previously visited step by clicking on the tab associated with that step. You must complete all steps before your changes will be confirmed. The Steps that appear above may vary depending upon the event selected. Upon the completion of this event, further instructions may be provided to you on the confirmation tab.

Click Save & Continue

Acceptance

Click I Accept and wish to Continue

• Employee, answering No to Actively at Work question, or not making a selection invalidates the application.
• Spouse, answering No to Hospitalized question invalidates the application.

Event Date

The Event Selected requires that you enter the date for which the Event occurred. In the field below, please enter the Event Date and then click the Save & Continue button.

Personal

Please review the Informational section(s) below. If any of the information displayed is incorrect, please correct it before proceeding.

Special Instructions - Employee, answering No to Actively at Work question, or not making a selection invalidates the application. Spouse, answering No to Hospitalized question invalidates the application.

Dependents

Please review the Informational section(s) below. If any of the information displayed is incorrect, please correct it before proceeding.

Add a dependent:

• Click select the add dependent link

Note: It is important that the Dependents section below reflects your actual dependents, as coverage eligibility depends upon this.

Benefits

Health Insurance is mandatory in the states/districts of California, Massachusetts, New Jersey, Rhode Island, Vermont, and the District of Columbia unless eligible employees can show proof of existing health coverage. Please see the plan details for specific information regarding each offered health plan. Preventive care is covered at 100% with both plans.

Please verify coverage requirements and regulations in your states/region with your insurance broker.

Click Save & Continue

Review

Please review each section displayed below for correctness. When you have completed reviewing the information and are sure it is what you intended to elect, click the Save & Confirm button above.

Special Instructions:

• Employee, answering No to Actively at Work question, or not making a selection invalidates the application.
• Spouse, answering No to Hospitalized question invalidates the application.

Confirmation

On the Confirmation tab, you will see the message "Thank you. Your event has been recorded and is now awaiting Administrative Approval. Click the link below to return to your Home Page. You will not be allowed to resubmit another event until this event has either been approved or denied. To return to your Homepage, click the link below."

Click Return to my Homepage