This version of the form is not currently in use and is provided for reference only. Download this version of
the document
for the current year.
Benefit Enrollment and Dental Benefits - Statutorily Authorized Group (Sag) Employees and Temporary/Seasonal Employees (Hired for Less Than 6 Months) is a legal document that was released by the New Hampshire Department of Administrative Services - a government authority operating within New Hampshire.
Q: What is the Benefit Enrollment and Life Event Change Form?
A: The Benefit Enrollment and Life Event Change Form is a document used by Sag and Temporary/Seasonal employees in New Hampshire to enroll in or make changes to their medical and dental benefits.
Q: Who is eligible to use this form?
A: Sag employees and Temporary/Seasonal employees hired for less than 6 months in New Hampshire are eligible to use this form.
Q: What is the purpose of the form?
A: The purpose of the form is to enroll in or make changes to medical and dental benefits for eligible employees.
Q: When should this form be completed?
A: This form should be completed when enrolling in or making changes to medical and dental benefits, or when experiencing a qualifying life event.
Q: What types of changes can be made using this form?
A: This form can be used to make changes such as adding or removing dependents, changing coverage levels, or updating personal information.
Q: Is there a deadline for submitting this form?
A: Deadlines may vary, so it's best to check with your employer's human resources department or benefits administrator for the specific deadline.
Q: Are there any requirements for supporting documentation?
A: Yes, depending on the type of change being made, supporting documentation such as birth certificates, marriage certificates, or proof of other insurance coverage may be required.
Q: What happens after I submit the form?
A: After submitting the form, your employer's human resources department or benefits administrator will process the changes and provide you with updated information about your medical and dental benefits.
Q: Can I make changes to my benefits at any time?
A: No, there are typically specific enrollment periods or qualifying life events that allow you to make changes outside of the regular enrollment period. It's best to check with your employer for the specific rules and deadlines.
Form Details:
Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Administrative Services.