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(On and Off Exchange)

(Short-Term Plans Only)

(Must have a compatible plan)

(Must have a compatible plan)

972.245.0266 | 888.456.3467 972.245.2455 (fax) Mobile App

In this section, you’ll find the election form that you’ll need to print, complete, and turn in. You’ll also find the enrollment forms which you may or may not need to complete – see instructions. Lastly, the cost sheet will show the amount you’ll pay for yourself and your dependents for each plan option available to you.

You are required to complete and return this form indicating whether you are enrolling in or waiving coverage.

Complete this form if you are enrolling in the group plan for the first time, adding or dropping dependents, or waiving coverage.

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