Insurance Forms
Annual Enrollment and Forms
- Annual Enrollment elections must be submitted through the Edison self-service portal. Active employees: Your agency benefits coordinator can also submit your Annual Enrollment elections for you electronically via a benefit form. See your ABC about this option.
- Enrollment Change Applications are not accepted for Annual Enrollment elections unless you are a new hire and within your 30-day initial enrollment period.
To request a printable form, complete the Print Request Form. Select your entity and provide the requested information before submitting the form.
- Enrollment Change Application – Active Members and COBRA 2027
- Certification of Eligibility for Dependents Placed with Head of Contract by Valid Placement Order
- Dependent Eligibility Certification for Dependent with Expired Placement Order
- Insurance Cancel Request Application 2027
- Dependent Eligibility Verification Documents
- Dental Only Application for Current Members (Retirees and COBRA only)
- Application to Continue Insurance at Retirement 2027
- Application for The Tennessee Plan
- Retiree Insurance Change Application 2027
- Insurance Cancel Request Application 2027
- Dental Insurance Application 2027
- Vision Insurance Application
- Dependent Eligibility Verification Documents
- Individual Authorization Agreement for Preauthorized Payment (ACH)