ASR Enrollment form for New Hire or Current Employee Changes

Please complete the form below to enroll in ASR Health, Dental and/or Vision insurance. Enrollment or changes must be made within 30 days of qualifying event date to be eligible for Special Enrollment.

ASR Enrollment Form

ASR Enrollment Form for Health, Dental & Vision Insurance.
  • Enrollee's Name
  • New Hire or Change
  • Address
  • Sex * Required
  • Marital Status * Required
  • Level of Coverage * Required
  • ASR Plan Election(s) * Required
  • Spouse/Partner Name
  • Spouse/Partner Sex
  • Dependent Child's Name 1
  • Dependent Child's Sex 1
  • Dependent Child's Name 2
  • Dependent Child's Sex 2
  • Do you have more than two(2) dependent children?
    Please click "yes" if you have more than 2 dependent children so Human Resources can reach out to you for further enrollment information.
  • Is your spouse/partner employed?
  • Is your spouse/partner eligible for insurance through an employer?
  • Has your spouse/partner elected coverage through their employer?
  • If yes, what coverage have they elected?
  • Address of Employer
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

If you need assistance please contact Jenn Williams or contact Jenn through Microsoft Teams.