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.

Form NameBenefeds Belated Enrollment
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesbenefeds enrollment change form, benefeds fedvip belated, benefeds belated form, fedvip belated change online

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











Last name











































































Address 1

































































































Address 2














































































































































































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


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

Dental plan

Vision plan


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




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

We chose the finest web programmers to create the PDF editor. The application will allow you to fill out the belated change form online document effortlessly and won't take up a great deal of your time. This convenient guideline can assist you to get going.

Step 1: Hit the button "Get form here" to get into it.

Step 2: After you have accessed the belated change form online editing page you may notice each of the actions you may use about your template from the upper menu.

The following segments will help make up your PDF form:

benefeds fedvip belated online spaces to complete

Fill in the Is this request for a FEDVIP, Dental plan, Vision plan, and continue on reverse fields with any details that are demanded by the software.

part 2 to completing benefeds fedvip belated online

The software will require you to write some necessary details to instantly fill out the part We will base our decision on the.

benefeds fedvip belated online We will base our decision on the blanks to fill

The Print name, Signature, Date signed, Required mmddyyyy, Required, Required, Mail to BENEFEDS PO Box, Fax to, and BEN area allows you to indicate the rights and obligations of both parties.

Filling in benefeds fedvip belated online step 4

Step 3: Hit the "Done" button. You can now export the PDF file to your electronic device. In addition, you may forward it by electronic mail.

Step 4: Generate duplicates of your file - it may help you refrain from potential future concerns. And don't worry - we don't reveal or check your details.

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