Health/Dental/Vision Enrollment and Changes – Human Resources

Welcome! We are so glad that you stopped by. This is the place to enroll, or change, decisions involving healthcare, dental, and vision elections. There is a lot of information to take in. Please contact hr.benefits@kzoo.edu with questions. We’ll be happy to assist you.

Healthcare Type

Health

Dental

Vision

Pre-65 Retirees

Links will open in a new screen

Health, Dental, Vision Enrollment and Changes

This form will adjust based on responses provided.

"*" indicates required fields

Your Name * Required

First Last

Email * Required

Can be a Kalamazoo College or personal email address

What brings you here today? * Required

I am a new employee. I am making my health-related selections.

I am a current employee. I need to change my health-related selections.

I am a pre-65 retiree. I need to change my health-related selections.

I am a pre-65 retiree and am making open enrollment changes.

Changes to health, dental, vision

This section includes the ability to change health, dental, and/or vision coverages for yourself and/or your eligible dependents.

Are you adding or removing coverage? * Required

I am adding coverage (health, dental, or vision)

I am dropping coverage (health, dental, or vision)

Who will be impacted by your change(s)? * Required

Me, the employee/retiree named above

My spouse/partner

My dependent child(ren)

Which coverages are you adding? * Required

Select one or multiple.

Health

Dental

Vision

Which health plan are you electing? * Required

Black Plan (Standard)

Orange Plan (Premium)

Which coverages are you dropping? * Required

Select one or multiple.

Health

Dental

Vision

When should this change be effective? * Required

The effective date must be within 30 days of completing this form

Month

Day

Year

Why are you making this change? * Required

Per regulation, there are a finite number of reasons for which a change to health, dental, and/or vision can be made outside of the open enrollment period.

Lost other coverage

Gained other coverage

Got married

Had a baby, adopted a child, or placed a child for foster care

Got divorced or legally separated and lost health insurance

Other

Upload file(s) to support the requested change. * Required

Drop files here or

Max. file size: 5 MB, Max. files: 3.

Pre-65 retiree changes to health, dental, vision

This section includes the ability to enroll/decline health, dental, and/or vision for yourself and/or your eligible dependents.

Are you adding or removing coverage? * Required

I am adding coverage (health, dental, or vision)

I am dropping coverage (health, dental, or vision)

Who will be impacted by your change(s)? * Required

Me, the employee/retiree named above

My spouse/partner

My dependent child(ren)

Which coverages are you adding? * Required

Select one or multiple.

Health

Dental

Vision

Which health plan are you electing? * Required

Black Plan (Standard)

Orange Plan (Premium)

Which coverages are you dropping? * Required

Select one or multiple.

Health

Dental

Vision

When should this change be effective? * Required

The effective date must be within 30 days of completing this form

Month

Day

Year

Why are you making this change? * Required

Lost other coverage

Gained other coverage

Got married

Got divorced or legally separated and lost health insurance

Had a baby, adopted a child, or placed a child for foster care

Open Enrollment

Other

Upload file(s) to support the requested change. * Required

Drop files here or

Max. file size: 5 MB, Max. files: 3.

New selections for health, dental, vision

This section includes the ability to enroll/decline health, dental, and/or vision.

Health Insurance

How do you want to handle health insurance at K? * Required

You will get a chance to share your dental and vision decisions shortly.

I want Kalamazoo College’s health insurance.

I am declining Kalamazoo College’s health insurance. I understand that I can change my decision during open enrollment or within 30 days of a qualifying event such as marriage, divorce, or a new child.

In addition to electing health insurance for yourself, is there anyone else for whom you would like to provide health insurance? * Required

I need to cover my spouse/partner.

I need to cover my child(ren) who are age 26 or under.

I would like to elect for myself only.

Which health plan are you electing? * Required

Black Plan (Standard)

Orange Plan (Premium)

Dental

How do you want to handle dental insurance at K? * Required

I want Kalamazoo College’s dental insurance.

I am declining Kalamazoo College’s dental insurance. I understand that I can change my decision during open enrollment or within 30 days of a qualifying event such as marriage, divorce, or a new child.

In addition to electing dental insurance for yourself, is there anyone else for whom you would like to provide dental insurance? * Required

I need to cover my spouse/partner.

I need to cover my child(ren) who are age 26 or under.

I need to cover myself only.

Vision

How do you want to handle vision insurance at K? * Required

I want Kalamazoo College’s vision insurance.

I am declining Kalamazoo College’s vision insurance. I understand that I can change my decision during open enrollment or within 30 days of a qualifying event such as marriage, divorce, or a new child.

In addition to electing vision insurance for yourself, is there anyone else for whom you would like to provide vision insurance? * Required

I need to cover my spouse/partner.

I need to cover my child(ren) who are age 26 or under.

I need to cover myself only.

Dependents

Spouse/Partner's Name * Required

First Middle Last

Spouse/Partner's Name * Required

First Middle Last

Spouse/Partner's Name * Required

First Middle Last

Spouse/Partner's Social Security Number * Required

Spouse/Partner's Date of Birth * Required

Month

Day

Year

Spouse/Partner's Sex * Required

Female

Male

Non-binary

Spouse/Partner's Social Security Number * Required

Spouse/Partner's Date of Birth * Required

Month

Day

Year

Spouse/Partner's Sex * Required

Female

Male

Non-binary

Spouse/Partner's Social Security Number * Required

Spouse/Partner's Date of Birth * Required

Month

Day

Year

Spouse/Partner's Sex * Required

Female

Male

Non-binary

Are you legally married to your spouse/partner? * Required

Non-married partners will need to successfully complete the Affidavit of Domestic Partnership with supporting documentation at https://hr.kzoo.edu/benefits/healthcare/domestic-partner/

I am legally married to my spouse.

I am not married to my partner.

Kalamazoo College requires spouse/partners who are employed elsewhere to indicate certain pieces of information before Kalamazoo College's coverage can begin. Is your spouse/partner employed? * Required

My spouse/partner IS employed and IS eligible for benefits.

My spouse/partner IS employed and IS NOT eligible for benefits.

My spouse/partner is not employed.

Are you legally married to your spouse/partner? * Required

Non-married partners will need to successfully complete the Affidavit of Domestic Partnership with supporting documentation at https://hr.kzoo.edu/benefits/healthcare/domestic-partner/

I am legally married to my spouse.

I am not married to my partner.

My spouse/partner IS employed and IS eligible for benefits.

My spouse/partner IS employed and IS NOT eligible for benefits.

My spouse/partner is not employed.

What coverages have your spouse/partner elected with their employer? * Required

Medical

Dental

Vision

My spouse/partner has declined medical, dental, and vision.

Is your spouse/partner's coverage equal or greater than 50%? * Required

This means that the insurance covers 50% or more of service costs after the deductible is applied.

Yes. Their coverage covers 50% or more of costs.

No. My spouse/partner’s coverage covers less than 50% of costs.

No. Medical, dental, and vision are not available through my spouse/partner’s employer, if any.

What coverages have your spouse/partner elected with their employer? * Required

Medical

Dental

Vision

My spouse/partner has declined medical, dental, and vision.

Is your spouse/partner's coverage equal or greater than 50%? * Required

This means that the insurance covers 50% or more of service costs after the deductible is applied.

Yes. Their coverage covers 50% or more of costs.

No. My spouse/partner’s coverage covers less than 50% of costs.

No. Medical, dental, and vision are not available through my spouse/partner’s employer, if any.

Provision for spouse/partner coverage

I understand and will ensure that my spouse/partner will enroll in their employer’s health/dental/vision, if required.

Insurance carrier and policy number * Required

Provision for spouse/partner coverage * Required

I understand and will ensure that my spouse/partner will enroll in their employer’s health/dental/vision, if required.

Insurance carrier and policy number * Required

What is the name of your spouse/partner's employer? * Required

Address of Spouse/Partner's employer * Required

Street Address Address Line 2 City State ZIP Code

What is the name of your spouse/partner's employer? * Required

Address of Spouse/Partner's employer * Required

Street Address Address Line 2 City State ZIP Code

Enter the email address of your spouse/partner to send them a copy of your submission.

A copy of your submission will be sent to the employee/retiree named above.

How many children are you insuring? * Required

One (1) child

Two (2) children

More than two children

How many children are you insuring? * Required

One (1) child

More than one child

Dependent Child's Name * Required

Child 1

First Middle Last

Dependent Child's Name * Required

Child 1

First Middle Last

Dependent Child's Name * Required

Child 1

First Middle Last

Dependent Child's Social Security Number * Required

Child 1: Enter zeros if the social security number is not assigned yet.

Dependent Child's Date of Birth * Required

Child 1

Month

Day

Year

Dependent Child's Sex * Required

Child 1

Female

Male

Non-binary

Dependent Child's Social Security Number * Required

Child 1: Enter zeros if the social security number is not assigned yet.

Dependent Child's Date of Birth * Required

Child 1

Month

Day

Year

Dependent Child's Sex * Required

Child 1

Female

Male

Non-binary

Dependent Child's Social Security Number * Required

Child 1: Enter zeros if the social security number is not assigned yet.

Dependent Child's Date of Birth * Required

Child 1

Month

Day

Year

Dependent Child's Sex * Required

Child 1

Female

Male

Non-binary

Child's Name * Required

Child 2

First Middle Last

Dependent Child's Social Security Number * Required

Child 2: Enter zeros if the social security number is not assigned yet.

Dependent Child's Date of Birth * Required

Child 2

Month

Day

Year

Dependent Child's Sex * Required

Child 2

Female

Male

Non-binary

Please provide the requested information for each child in addition to two children. * Required

Include for each child: Full name, social security number, date of birth, and sex

Please provide the requested information for each additional child. * Required

Include for each child: Full name, social security number, date of birth, and sex

Additional Comments

Consent(s) and Release(s)

Authorization for Release of Protected Health Information. * Required

Employee Release of Protected Health Information.

By signing below, as an employee or dependent, I authorize the use or disclosure of my individually identifiable health information by or to any family family member, any health care provider, the Plan Sponsor, the insurer/TPA of the Plan, or any other entity providing services in connection with the Plan in order to process my enrollment in the Plan or to process any claim for my Plan benefits. This authorization is effective until the date I terminate enrollment in the Plan. Further, I have read and understand the following: (1) I may revoke this authorization at any time before its expiration date by notifying the Plan in writing, but the revocation will not have any effect on any actions that Plan took before it received the revocation, (2) I may se and copy the information described on this authorization if I ask for it, (3) I am not required to sign this authorization to receive my health care benefits (enrollment, treatment, or payment), and (4) the information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity.

Authorization for Release of Protected Health Information. * Required

Spouse/Partner Release of Protected Health Information.

Authorization for Release of Protected Health Information. * Required

Dependent Child(ren) (age 18+) Release of Protected Health Information, or Parent/Guardian Release if Dependent Child(ren) is/are Minors