Station Staff

Station Staff Enrollment Materials Portfolio

This file contains all of the forms that station staff/employers may need to submit in order to complete enrollment. The portfolio includes a checklist which will instruct you which forms are optional, and which are required in order to enroll in coverage.

Employer Checklist for Enrollment

A checklist of all the necessary forms and materials for station staff to receive coverage. 

Employer Request for Staff Coverage Form

Employers should submit this form to notify the Plan of participant’s employment start date and requested coverage.

Premium Payroll Deduction Agreement Form

Use this form if you'd like to have your premiums deducted from your wages on a pre-tax basis over the course of a calendar year.