Healthflex Enrollment-Change Form Instructions


Part 1

  • Fill in your name, SSN, 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
  • Appointment: Full-Time
  • 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


Part 2

  • 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
  • Leave the special notes section blank.


Part 3

  • 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.


Part 4

  • Choose your plans based on the plan information found at 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. 


Part 6

  • Sign and date


Return this form to the Conference Benefits Office via email at AND