Pre-65 Retiree/LTD ASR Enrollment Form

ASR Pre-65 Retiree/Spouse/LTD Enrollee Open Enrollment Form

ASR Pre-65 Retiree/Spouse/LTD Enrollee Open Enrollment Form for Health, Dental & Vision Insurance.
  • Enrollee's Name
  • 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
  • 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