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| An Important Message Regarding Open Enrollment |
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Note: Changes made during this Open Enrollment period become effective on January 1, 2007.
NJ State Health Benefits Program
- Please read the instructions attached with the form carefully before filling out the form and complete all relevant entries.
- The open enrollment period ends on October 31, 2006, so please ensure to submit a completed and signed form latest by October 31, 2006 to the Office of Human Resources (Room 500, 5th Floor, East Building). Please mark it to the attention of Judith Gregorio, Benefits Assistant.
- If you are using this opportunity to add a dependent(s), please ensure that details of ALL the dependents are included in the form, irrespective of the fact that some of them may already be enrolled in your plan. Failure to do so will result in coverage for only the dependent(s) mentioned in the form.
- In case you are adding your spouse to the plan please attach a copy of your marriage certificate. In case you are adding your domestic partner please attach a copy of the “Certificate of Domestic Partnership”. For obtaining a Certificate of Domestic Partnership contact your local Registrar. A list of the local registrars is available at www.state.nj.us/health/vital/regbycnty.shtml
- If you are adding a dependent child who is under 23 years and has a different last name than yours, then you are also required to submit an “Affidavit of Dependency”. The form is available at www.njit.edu/humanresources/resources/forms.php and can also be obtained from HR office.
- If your dependents do not have a SSN, please provide a copy of their visa or passport showing their photograph and date of arrival in the US.
- Adjunct faculty can only enroll in NJ Plus medical and prescription drug plan and must pay the full cost of the coverage.
Tax$ave Flexible Spending Accounts
- You must be enrolled in the NJ State Health Benefits Program in order to apply for Tax$ave Flexible Spending Accounts.
- The Tax$ave Flexible Spending Accounts require active enrollment each year.
- You can enroll by calling Horizon’s automatic voice response system at 1-800-224-4426, select option 1 for Flexible Spending Accounts, then option 2 for enrollment and follow the instructions.
- You can also enroll by submitting forms at the Human Resources Department. The forms are available at: www.njit.edu/humanresources/divisions/benefits/
Open Enrollment Forms:
.....1. NJ State Health Benefits - use this form to change your health/prescription drug plan
.....2. NJ State Dental Benefits - use this form to change your dental plan
.....3. NJ State Health & Dental Benefits - use this form to change all plans (health,.... ........prescription drug and dental)
....4. Flexible Spending Enrollment Form
.....5. Claim for Reimbursement Form
In case of any questions please contact Judith Gregorio at X 3144 (e-mail: judith.gregorio@njit.edu) or Pat Lawrence at X 3143 (e-mail: patricia.lawrence@njit.edu)
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