2018 Open Enrollment

Who needs to complete this?

  • Active Full Time Clergy, regardless of current coverage
  • Lay Employees who are currently covered by the conference plan

Failure to complete the open enrollment form by November 17 may result in a loss of coverage.

*First Name
*Last Name
*Phone Number
*Name of Church
*Relationship to Church
Lay Employee
*What plan would you like to choose?
Blue Shield PPO
Kaiser HMO
Dental Only
I decline health coverage for 2018
*Is this a new plan for you?

If yes please complete the correct enrollment form below. 

Once completed, send the completed form to the Board of Pensions

Email: bop@bopumc.net
Fax: 916-913-1447
Mail:  1337 Howe Avenue, Suite 200, Sacramento, CA 95825

*If declining conference coverage, where will you be getting your insurance in 2018
Not Applicable - I am on the conference plan
Through my spouse
Through Covered California or a government exchange (e.g. Obamacare)
Through another source (e.g. another job, independent broker)
*How many people will you be covering?
Only me
Me and my spouse
Me and one child
My family - Spouse and/or Child(ren)
Name of Covered Dependent 1
Dependent 1 Date of Birth
Name of Covered Dependent 2
Dependent 2 Date of Birth
Name of Covered Dependent 3
Dependent 3 Date of Birth
Name of Covered Dependent 4
Dependent 4 Date of Birth
Name of Covered Dependent 5
Dependent 5 Date of Birth
List the Names and Dates of Birth for any Additional Covered Dependents
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