[Montgomery County, MD] 2023 Active Employee Health and Life Insurance Election Form

Dear MCG Employee:

The 2023 Health & Life Insurance Election Form for active employees is now electronic; making it easier for you to submit your enrollment elections online without requiring the need to complete paper forms or return them to OHR manually. TIP: Opening in Chrome as your web-browser allows for the best user experience.

To complete your 2023 Health & Life Insurance Election form, please read the message below, check the box that you are willing to complete a digital version of the election form and proceed to complete your form online.

Please use this enrollment form for the following reasons:

1. You are a new hire enrolling in health insurance plans within your initial 60-day window.

2. You have experienced a qualifying life event within the past 60 days and need to make changes to your 2023 benefit elections.

Qualifying life events are:

Marriage, divorce, remarriage
Birth or adoption of a dependent
Death of a dependent
Loss of coverage under another plan
Dependent's loss of coverage under another plan
Court-ordered custody of minor child(ren)
Moving out of your plan’s network area (applies to Kaiser participants only).

If your form and necessary documentation are submitted after the 60-day window, your request will be denied and you will need to wait until the next annual Open Enrollment to enroll and/or make changes to your plans.

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 Health & Life insurance plans, please visit the Office of Human Resources (OHR) Health Insurance Webpages.

All health insurance questions should be directed to OHR's MC311 Customer Service Center at 240-777-0311 (Mon-Fri 8 am - 5 pm) to open a service request. A member of the health insurance team will respond to your service request in the order it is received. TIP: Please provide an email address at the time you place your Service Request. This will ensure the fastest response possible.

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.

Additionally, a printed confirmation statement will be mailed to your home address within 10-14 business days after you submit your completed form.

Please check that you agree before continuing.

By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.

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