Healthflex Enrollment-Change Form Instructions
Fill in your name, birth date, and contact information.
Participant #: leave blank – we can look that number up in the Benefits Office.
Conference/Plan Sponsor/Employer: 711-North Georgia
Employer #: leave blank – we can look that number up in the Benefits Office.
Date of Hire: leave blank
Status Effective Date: date of appointment (or life event if adding a spouse/child to plan)
Last day worked: leave blank
Weekly hours: leave blank
Event Effective Date: date of appointment (or life event)
Life Status Event
New clergy/lay staff: New Enrollment, Newly Eligible
To add a spouse or children: Add Dependent for Covered Participants, choose based on if you are adding someone for the first time, or if your spouse or child under 26 lost other coverage
To remove a dependent because they have gained other insurance: Delete Dependent for Covered Participants: Dependent gains other coverage
Leave the special notes section blank.
Enter yourself, your spouse, and your children, EVEN if you are not covering them.
Provide the information requested. In the Cover selection, you will choose yes or no as to whether they will be included on the health insurance plan. If you are full time clergy, your answer is Y.
To add a baby/adopted child: just enter the child's information and under cover, select Y. You do not have to cover a baby under dental and vision, even if you are covering them under medical.
To remove a dependent because they have gained other insurance: only enter the dependent and then under cover, select N
Choose your plans based on the plan information found at
https://www.ngumc.org/healthflex under HealthFlex Insurance Information.
Do not waive the HSA because you can not change your mind during the year if you waive it when you make your election.
Part 5 is not applicable to full-time appointed clergy. Lay staff may opt out of the Conference health insurance plan; however, full-time appointed clergy may not as per the rules established by the Annual Conference.
Return this form to the Conference Benefits Office via email at
email@example.com AND firstname.lastname@example.org. Scanned copies only. NO PHOTOGRAPHS