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Dear Participating Agency Employee:
Please use this enrollment form ONLY if you are making Open Enrollment changes for the benefit plan year 2022. If you are not making any changes during Open Enrollment, then you do not need to submit a new form.
Open Enrollment changes are due by 5pm on Friday, October 8, 2021. All Open Enrollment changes will be effective on January 1, 2022.
If you are enrolling NEW dependents during Open Enrollment, please attach the necessary required documentation before submitting this enrollment form. For more information about required documentation, click HERE. To upload, click on the attachment (paperclip) symbol on the bottom or left of the page (depending on your browser). For more information about the changes you can make during annual Open Enrollment, please visit the Open Enrollment website. .After you submit your form, you will see a pop-up message that allows you to download a copy of your form. You are strongly encouraged to download the form to keep a copy for your records. You will also receive an email that your form has been submitted. This email acts as confirmation that your form was successfully submitted.
Participating Agency employees are employees who work for the following employers:
Arts & Humanities Commssion,
Town of Chevy Chase,
Housing Opportunities Commission,
Revenue Authority,
Strathmore Hall,
Town of Garrett Park,
Washington Suburban Transit Commission,
Bethesda Urban Partnership,
Town of Chevy Chase View,
Chevy Chase Village,
Village of Friendship Heights,
Montgomery Community Television,
Town of Somerset,
Maryland National Capital Park & Planning Commission (MNCPPC),
State Department of Assessment & Taxation,
Board of Appeals,
Montgomery County Volunteer Fire & Rescue Association
