Insurance Election for CLE Please enable JavaScript in your browser to complete this form.Applicant NameFirstLastDropdown *I am NOT making changes to my benefitsI AM making changes to my benefit electionsMedical Coverage *Employee Only $60.82Employee + Spouse $462.51Employee + Child(ren) $386.34FAMILY $770.81Waive (opt out)Dental *Employee only $12.22Employee + Spouse $24.45Employee + Child(ren) $27.22Family $42.81Waive (opt out)Vision *Employee Only $2.84Employee + Spouse $5.67Employee + Chil(ren) $6.07Family $9.69Waive (opt out)Accident *Employee Only $4.48Employee + Spouse $10.84Employee + Child(ren) $13.60Family $17.98Waive (opt out)Voluntary Life *Employee Only SpouseChild(ren)Waive (opt out)Note: New enrollments and enrollment changes require a completed application/change form. *Voluntary Life Coverage and cost information can be found in the Standard Booklet.SignatureClear SignatureDate *Submit
