Skip to form

OHR.HITS@montgomerycountymd.gov

SeamlessDocs




Dear MCG Employee:

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 2020 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 is 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 of the page.

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.
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.
Signature HereClick to Sign

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

x

Signature Type

Type Draw Upload Custom
Clear Signature

Signature will be applied to the page. You will have a chance to review after signing.

Check this box to continue

x

Additional Signatures Required

Upload Attachment(s)

Please upload the necessary required documentation (i.e. marriage and birth certificates).  Click HERE for more information on required documentation.

There is a 250MB limit on each attachment.

Official state marriage certificate (certified by appropriate state or county official) Click Here to Upload
State birth certificate Click Here to Upload
Adoption or placement for adoption papers Click Here to Upload
Medical plan verification of disability prior to age 26 (For disabled dependent over 26) Click Here to Upload
Court order granting legal custody (legal guardianship) Click Here to Upload
Proof of new/cancelled coverage documentation (Gaining/losing coverage elsewhere) Click Here to Upload
Death certificate Click Here to Upload