2025 Open Enrollment Forms

Health Insurance Change Form - Use this form in the following scenarios: You currently have a family plan and are adding/dropping a dependent or you have a family plan and are moving to a single plan. 

Health Insurance Enrollment Form - Use this form if you are electing new coverage.  

Dental Enrollment/Change Form - Use this form if you are making any changes to your dental plan or electing new coverage.

Vision Enrollment/Change Form - Reach out to Gina or Audrey to request the form.

Life Insurance - Employees are only able to add $10,000 for themselves if already enrolled. If more than $10,000 is requested or would like to newly enroll themselves or their spouse, the evidence of insurability will need to be completed along with the Enrollment Form below.

Annual Voluntary Life Enrollment/Change Form

Evidence of Insurability Form

Please complete and return these forms to Gina or Audrey in Payroll. 

If you have any questions regarding these forms, please reach out to Gina Hatcher or Audrey Chapin in Payroll. 

Gina Hatcher                                                                                                 Audrey Chapin

Payroll/Benefits Specialist                                                                          Payroll/Benefits Specialist 

712-328-4848 or Ext. 3015                                                                       712-328-4848 or Ext. 3027                                                   

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