Churchill Downs IncEMPLOYEE VOLUNTARY BENEFIT INQUIRY

Churchill Downs Inc

EMPLOYEE VOLUNTARY BENEFIT INQUIRY

Voluntary Benefit Changes regarding the below listed benefits ONLY.

Please complete and submit this form and someone from our Voluntary Benefits Service Team will contact you within two business days.

If you have questions regarding any benefits not listed below, please visit your employer's Benefits Resource Portal.

Full Employee Name*

Last Four Numbers Of SSN*

Preferred Phone Number*

Phone

Email Address*

Enrollment Type*

New Hire Enrollment

Open Enrollment

Qualifying Life Event

If you are a new hire, please elect these benefits during your new hire enrollment window. Log in to your enrollment and elect/waive coverage through checkout. If you missed the deadline to enroll, a qualifying life event is required to enroll or make changes.

Reason For Voluntary Benefit Inquiry*

Benefit Amount Increase

Add / Remove Dependent

Remove A Benefit

Add / Remove Dep - Select Benefit*

Please indicate in the notes below which dependent(s) you would like to add to or remove from the selected benefit(s).

Accident

Critical Illness

Universal Life Events-Spouse

Remove Benefit - Select Benefit*

Select the benefit(s) you are wishing to remove.

Accident

Critical Illness

Universal Life Events - Employee

Universal Life Events - Spouse

Amount Increase - Select Benefit*

Select the benefit(s) you are requesting to remove.

Critical Illness

Universal Life Events - Employee

Universal Life Events - Spouse

Notes / Comments

*NOTE: This is limited to the voluntary benefits. For any benefits not listed here, please refer to your company's Benefits Resource Portal at the link above.

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