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Rev. 7/23/19 6000-f-13b
ALL PORTIONS OF THE ELECTION FORM MUST BE COMPLETED OR IT WILL BE SENT BACK FOR
COMPLETION PRIOR TO PROCESSING.
Review your current benefits, the available plans and options. Then select the benefit options most suited to
your personal needs.
Social Security Numbers are required for enrollment. If you do not provide a Social Security Number for
yourself or your dependents, health insurance coverage cannot be provided. Exception: A newborn's Social
Security number will be accepted after enrollment, but must be sent in once it is received.
You must drop all of your ineligible dependents. When your dependents no longer meet eligibility
requirements, their coverage ends the last day of the month they became ineligible. You may be responsible
for any cost for services received while your dependent was incorrectly listed as eligible.
Members may make changes to their plan if they experience a qualifying status change, but they may not elect
a different plan.
If you experience a qualifying event that allows you to cancel your health insurance, you can only enroll
again during the next annual open enrollment period or if you have a qualifying status change event.
Qualifying status change events include those listed on this form, and may require that you provide proof
that you have gained or lost group health care coverage.
You should receive plan information and ID cards in a timely manner from ARBenefits. If you do not, call
ARBenefits at 1-877-815-1017 (When you hear the recording, Just Press One).
Your elections will remain in effect for the remainder of the calendar year unless you experience a
qualifying status change event, as defined by the ARBenefits Summary Plan Description.
Your effective date of coverage will be the first of the month following date of application and following your
qualifying event. Note: The qualifying event date is not the date of eligiblity.
Members who turn age 65 or become eligible for Medicare must send in a copy of their Medicare card to
Proof of dependent eligibility is required. Examples of required documentation are: birth certificates,
marriage licenses, spousal affidavit, court documents and a Certificate of Credible Coverage for loss of
Please mail or fax your completed and signed Health Insurance Election Form to:
P.O. Box 15610
Little Rock, AR
For assistance, contact ARBenefits at 1-877-815-1017 Monday through Friday, from 8:00 a.m. to 4:30 p.m. CST.