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Enrollment time frames and document requirements

Newly eligible employees

Benefit​ ​Documents ​Requirement ​Guidance

Medical/Dental

  • Employee Enrollment/Change form* (full benefits) 2022
  • Employee Enrollment/Change form* (medical only) 2022

If enrolling dependents:

​No later than 31 days after the date the employee becomes eligible (generally the date of employment).
​Life Insurance

No later than 31 days after the date the employee becomes eligible.

Employee must also submit a statement of health/EOI if requesting more than the guaranteed issue amount or after 31 days of eligibility.

​LTD Insurance

​No later than 31 days after the date the employee becomes eligible.

Employee must also submit an EOI form if requesting to enroll in or increase employee-paid LTD after the 31 days of eligibility.

​FSA/DCAP
(state agencies and
higher education only)
​No later than 31 days after the employee becomes eligible for benefits.
​Auto/Home Insurance Get a quote online or contact a local Liberty Mutual office ​Anytime

*If the employee does not return the forms within the required timeframes referenced above, default the employee as a single subscriber (no dependents enrolled), to Uniform Medical Plan Classic, Uniform Dental Plan, basic life, basic AD&D, and employer-paid LTD, and employee-paid LTD at the 60 percent coverage level.

Special Open Enrollment Event:

Benefit ​Documents Requirement​ ​Guidance

Medical/Dental

  • Employee Enrollment/Change form* (full benefits) 2022
  • Employee Enrollment/Change form* (medical only) 2022

If enrolling dependents:

​No later than 60 days after the date of the event that triggered the special open enrollment.

Enrollment due to loss of other coverage and dependents moving to the U.S. must be entered into the insurance system by PEBB.

FSA/DCAP
(state agencies and
higher education only)
​No later than 60 days after the employee becomes eligible for benefits.

Regaining Eligibility for the Employer Contribution:

Employees returning from approved leave without pay (LWOP), educational leave, military leave, or time-loss benefits under worker's compensation

​Benefit ​Documents​ Requirement​​ Guidance​

Medical/Dental

  • Employee Enrollment/Change form* (full benefits) 2022
  • Employee Enrollment/Change form* (medical only) 2022

If enrolling dependents:

​No later than 31 days after the date the employee regains eligibility for benefits.
Life Insurance​ ​No later than 31 days after the date the employee regains eligibility for benefits.

​LTD Insurance

​No form is required to reinstate LTD insurance in place prior to leave if:

  1. Employee was eligible to self-pay and
    chose to self-pay, or
  2. Employee was not eligible to self-pay

If employee was eligible to self-pay (educational leave or military leave) and did not, the employee must submit the following for carrier approval:

If a form is required:

No later than 31 days after the date the employee regains eligibility for benefits.

FSA/DCAP
(state agencies and
higher education only)

​To resume the FSA/DCAP:

​No later than 60 days after the employee regains eligibility for benefits.

*If the employee does not return the forms within the required timeframes referenced above, default the employee as a single subscriber (no dependents enrolled), to Uniform Medical Plan Classic, Uniform Dental Plan, basic life, basic AD&D, and employer-paid LTD, and employee-paid LTD at the 60 percent coverage level.

Note: The employee who regains eligibility for the employer contribution for benefits has experienced an event that triggers a special open enrollment. Their 60 days begins the date the employee regains eligibility for the employer contribution. See the special open enrollment section above and Policy 45-2, Addendum 45-2a for more information.