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 *

First Last

Email *

Can be a Kalamazoo College or personal email address

What brings you here today? *

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.

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? *

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

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

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

Me, the employee named above

My spouse/partner

My dependent child(ren)

Which coverages are you adding? *

Select one or multiple.

Health

Dental

Vision

Which health plan are you electing? *

Black Plan (Standard)

Orange Plan (Premium)

Which coverages are you dropping? *

Select one or multiple.

Health

Dental

Vision

When should this change be effective? *

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

Why are you making this change? *

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. *

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? *

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

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

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

Me, the employee named above

My spouse/partner

My dependent child(ren)

Which coverages are you adding? *

Select one or multiple.

Health

Dental

Vision

Which health plan are you electing? *

Black Plan (Standard)

Orange Plan (Premium)

Which coverages are you dropping? *

Select one or multiple.

Health

Dental

Vision

When should this change be effective? *

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

Why are you making this change? *

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

Other

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

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? *

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? *

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? *

Black Plan (Standard)

Orange Plan (Premium)

Dental

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

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? *

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? *

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? *

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 *

First Middle Last

Spouse/Partner's Name *

First Middle Last

Spouse/Partner's Name *

First Middle Last

Spouse/Partner's Social Security Number *

Spouse/Partner's Date of Birth *

Spouse/Partner's Sex *

Female

Male

Non-binary

Spouse/Partner's Social Security Number *

Spouse/Partner's Date of Birth *

Spouse/Partner's Sex *

Female

Male

Non-binary

Spouse/Partner's Social Security Number *

Spouse/Partner's Date of Birth *

Spouse/Partner's Sex *

Female

Male

Non-binary

Are you legally married to your spouse/partner? *

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? *

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? *

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? *

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? *

Medical

Dental

Vision

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

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

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? *

Medical

Dental

Vision

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

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

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.

Insurance carrier and policy number *

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

Address of Spouse/Partner's employer *

Street Address Address Line 2 City State ZIP Code

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

Address of Spouse/Partner's employer *

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? *

One (1) child

Two (2) children

More than two children

How many children are you insuring? *

One (1) child

More than one child

Dependent Child's Name *

Child 1

First Middle Last

Dependent Child's Name *

Child 1

First Middle Last

Dependent Child's Name *

Child 1

First Middle Last

Dependent Child's Social Security Number *

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

Dependent Child's Date of Birth *

Child 1

Dependent Child's Sex *

Child 1

Female

Male

Non-binary

Dependent Child's Social Security Number *

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

Dependent Child's Date of Birth *

Child 1

Dependent Child's Sex *

Child 1

Female

Male

Non-binary

Dependent Child's Social Security Number *

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

Dependent Child's Date of Birth *

Child 1

Dependent Child's Sex *

Child 1

Female

Male

Non-binary

Child's Name *

Child 2

First Middle Last

Dependent Child's Social Security Number *

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

Dependent Child's Date of Birth *

Child 2

Dependent Child's Sex *

Child 2

Female

Male

Non-binary

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

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

Please provide the requested information for each additional child. *

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

Additional Comments

Healthcare Type

Health, Dental, Vision Enrollment and Changes

Changes to health, dental, vision

Pre-65 retiree changes to health, dental, vision

New selections for health, dental, vision

Health Insurance

Dental

Vision

Dependents

Consent(s) and Release(s)