Forms-2013 Open Enrollment

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Forms

Forms-2013 Open Enrollment

Don’t know what form to complete? No problem!

See if your situation falls into one of these categories. If you don’t see one that fits, please call please contact a member of the Human Resources-Benefits team at 595-2133, 595-6246 or 595-3195 or e-mail benefits@stjude.org.

Health insurance plans

I am not currently enrolled in medical, dental or vision and want to enroll for 2013. Health Plan Enrollment Form
I am currently enrolled in dental and/or vision only and want to enroll in the medical plan for 2013. Additions/Deletions/Enrollment in Health Plan Form
I am currently enrolled in Choice and want to switch Select (or vice versa) for 2013. Health Plan Enrollment Form
I am currently enrolled in a medical plan (Select or Choice) and want to add dental and/or vision for 2013. Additions/Deletions/Enrollment in Health Plan Form
I want to add or delete a dependent from my plan for 2013 (medical, dental, vision). Additions/Deletions/Enrollment in Health Plan Form
I want to add my same gender domestic partner to my health plan coverage for 2013 (medical, dental and/or vision). Same Gender Domestic Partner Form. Download the policy.
I want to order my prescription drugs by mail. Caremark Mail Order Prescription Form
I need a Caremark Brand Penalty Exception Form.

Life insurance

I want to increase my Additional Life Insurance (.5x, 1x, 2x, 3.5x). Evidence of Insurability Form and Basic Life Insurance Form
I want to add or delete a dependent from my plan for 2012 (dependent life insurance). Dependent Life Enrollment Form
I want to add or delete a dependent from additional dependent life insurance. Spouse and Dependent Additional Life Form

Group Legal Plan

I want to enroll in the Legal Plan for 2013. Legal Plan Enrollment Form

Flexible Spending Account

I want enroll in a Healthcare and/or Dependent Care Flexible Spending Account for 2013. Flexible Spending Account Enrollment Form

St. Jude Retirement Account

I want to enroll or change my contribution to the St. Jude Retirement Account. Retirement Salary Reduction Agreement Form

Aflac

I want to enroll in Aflac. See the Aflac rate chart.

Cancellation of Benefits

I want to cancel any or all current coverage for 2013 (i.e. medical, dental, vision, additional life, 529 College Savings Plan). Cancellation of Benefits Form

Leave Programs

I want to request a leave of absence. Leave of Absence Request Form and Certification of Health Care Provider Form

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