Benefeds Belated Enrollment PDF Details

At the start of this semester, I was just about to register for classes. However, my mom told me that she had forgotten to send in the financial aid paperwork and that it would be too late for me to enroll. She said that I could wait until next semester or take a leave of absence so I wouldn't have any more time on my hands. But then she found out about Benefeds Belated Enrollment! Now, I can still get all the credit hours needed for graduation without having any other commitments while also saving some money because they are offering discounts on registration fees.

Here is the details in regards to the PDF you were looking for to complete. It will tell you how much time it will require to finish benefeds belated enrollment, what parts you will have to fill in, and so on.

QuestionAnswer
Form NameBenefeds Belated Enrollment
Form Length2 pages
Fillable?Yes
Fillable fields36
Avg. time to fill out7 min 46 sec
Other namesbenefeds belated enrollment form, belated change form online, benefeds fedvip belated online, benefeds belated form fill in

Form Preview Example

Federal Employees Dental and Vision Insurance Program (FEDVIP)

Belated Enrollment/Change Form

Use this form only to request approval for a belated FEDVIP enrollment, change to an existing FEDVIP enrollment, or cancellation of your FEDVIP enrollment.

We will consider your request if you were unable to perform, due to specific reasons beyond your control, the requested action during the Federal Benefits Open Season or within 60 days of a qualifying life event (QLE) or becoming a new

or newly eligible employee. (Examples of a QLE may be a change in family status that results in the increase or decrease in the number of eligible family members or an employee being restored to civilian status after serving in the uniformed services.) BENEFEDS must receive your completed form within three months of the last day of the Federal Benefits Open Season, your QLE date, or your new hire or newly eligible date. Incomplete forms will not be processed.

Section A: Contact Information

Provide as much accurate information as possible. We cannot process your request if we cannot reach you.

First name

 

 

 

 

 

 

 

 

M.I.

 

Last name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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City

 

 

 

 

 

 

 

 

 

 

 

State/Territory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

Zip/Foreign postal code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BENEFEDS user ID if applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone

 

 

 

 

 

Other phone

 

 

 

 

 

 

 

 

 

 

Best times to call you about your request

Section B: Information about Your Request

Please answer all applicable questions.

1. This request is for a:

new enrollment

 

change to an existing enrollment

cancellation of an enrollment

2.If this is NOT a Federal Benefits Open Season request and involves a QLE or a new hire or newly eligible request, please enter your QLE, new hire, or newly eligible date.

Date of QLE, new hire, or new eligibility

(mm/dd/yyyy)

3. Is this request for a FEDVIP dental plan and/or a FEDVIP vision plan?

Dental plan

Vision plan

CONTINUE ON REVERSE

4. Below are the valid reasons for which approval of this request will be considered.

uYou had no access to a telephone or the Internet for the entire duration of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

uYou had a significant medical emergency for yourself or an immediate family member and you were unable to perform your requested action for a significant portion of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

uA member of your immediate family passed away and you were unable to perform your requested action during the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

Please explain why you could not enroll, make a change, or cancel your enrollment during the eligible time frame.

We will base our decision on the information you provide, so please be as detailed as possible. While we review this information, we may request additional documentation to support your reason.

Please note: We will send you a written notice of our decision. If your request is approved, the following points apply.

uYou will have 30 days from the date on your approval letter to contact BENEFEDS to execute your request.

uPer Federal law, a belated enrollment, change, or cancellation must be retroactive to the effective date it would originally have been, had the request for the change been received within the eligible time frame.

uIf the change results in past due premiums, Federal law states that these premiums must be paid by direct bill. Failure to make this direct bill payment will result in a termination of your enrollment.

Section C: Signature and Mailing / Fax Instructions

Print name

(Required)

Signature

(Required)

Date signed//

(Required: mm/dd/yyyy)

Mail to: BENEFEDS | P.O. Box 797 | Greenland, NH 03840-0797

Fax to: 1-877-827-3291

 

 

BEN09007 1112

How to Edit Benefeds Belated Enrollment Online for Free

The notion supporting our PDF editor was to allow it to become as simple to use as possible. You will find the general process of filling in belated change form online stress-free should you stick to these steps.

Step 1: This website page includes an orange button stating "Get Form Now". Please click it.

Step 2: So, you're on the form editing page. You may add text, edit current details, highlight certain words or phrases, insert crosses or checks, insert images, sign the form, erase needless fields, etc.

All of these areas are inside the PDF form you'll be creating.

portion of gaps in benefeds enrollment change form

You should fill up the please enter your Q, LE Date of Q, LE mm, dd, yyyy Dental plan, Vision plan, and continue on reverse field with the requested data.

stage 2 to filling out benefeds enrollment change form

The application will ask you to note some necessary data to instantly fill out the area We will base our decision on the.

Finishing benefeds enrollment change form step 3

You'll need to identify the rights and obligations of all parties in section Print name, Signature, Date signed, (Required: mm, dd, yyyy (Required), (Required), Mail to: BENE, FEDS | P, Fax to: 1, 877, 827, 3291 and BEN, 09007 1112.

step 4 to completing benefeds enrollment change form

Step 3: After you have clicked the Done button, your form will be accessible for export to each gadget or email you indicate.

Step 4: It's going to be better to save copies of your document. You can rest assured that we are not going to display or view your information.

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