After-Tax Benefit Change Form

After-Tax Benefit Change Form

Please complete this form if you would like to make changes to your after-tax benefit elections. Changes made mid-year will be effective the first day of the month after submission of this form.

Click here to access the Benefits Guide

Please review the benefit plan information and bi-weekly premiums BEFORE making your selection(s).

Questions? Contact HR Benefits at benefits@hendrickhealth.org or call 325-670-3163

Employee ID*

Employee First Name*

Employee Last Name*

Date of Birth*

Preferred Email*

Preferred Phone Number*

Confirm which plan year this After-Tax Benefit Change should apply.

Select or enter value

After-Tax Plans

Optional Life Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

Disability Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

Accident Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

Hospital Indemnity Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

Critical Illness Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

Trustmark Universal Life Insurance

Please make your selection. If no change is requested, please skip.

Select or enter value

LifeLock Identity Theft Protection

Please make your selection. If revising existing coverage, Plan Election (Benefit Premier or Benefit Essential) will remain the same. If no change is requested, please skip.

Select or enter value

ARAG Legal

Please make your selection. If no change is requested, please skip.

Select or enter value

Employee Authorization

Employee Signature*

I understand that by signing and submitting this form, I am making an election to change the plans indicated above effective the first day of the month after submission of this form. I authorize Hendrick to inform appropriate insurance carriers of my election change(s). I verify that the information on this form is true and correct.

Life & Disability Insurance

I understand I can elect to drop this coverage mid-year; however, should I choose to re-enroll, I will need to do so during Annual Enrollment and will be required to complete Evidence of Insurability and may be denied coverage.

My electronic signature is the same as my written signature.

Type your first and last name as your electronic signature.

Confirmation

We highly recommend checking the box "Send me a copy of my responses" for confirmation your submission was successful.

Send me a copy of my responses

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