Benefits Enrollment Checklist

Benefits Enrollment Checklist
Please complete this form and submit along with all required forms and documentation for each desired benefit within 30 days of your start date of employment.

NOTE: Completing this form alone DOES NOT enroll you in benefits.

For more information about each of these benefits, including your eligibility for each, please visit the benefits webpage.
First Name
Last Name
Email
Please use your City email address if you have one. example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Department
Start Date of Employment

MonthDayYear
This is the first day you started working with the City.
Current Date

MonthDayYear
Date
Number of day passes
As a new hire, you have 30 days to enroll in benefits after which time enrollment will not be possible. Should you have a qualifying event at any time during your employment with the city, the qualifying event would allow you to make a change to your benefits within 30 days of its effective date. Outside of that, you will not be able to make a benefits change until annual open enrollment. Open Enrollment for health insurance takes place each February with changes effective as of April 1st and for flexible spending each November with elections effective January 1st.
Health Insurance

(Coverage options through Blue Cross Blue Shield and Harvard Pilgrim Health Plan)
Health Plan Options:
- Blue Cross Blue Shield - Blue Choice
- Blue Cross Blue Shield - HMO Blue
- Harvard Pilgrim Health Care
Please note that completion of the waiver form is required to decline health insurance with the City.
What would you like to do with your health insurance benefit?
Go here to request your health insurance enrollment form(s) or health insurance waiver form.
Dental/Vision Insurance

(Coverage through Cambridge Dental & Vision Fund)
Note that Dental and Vision insurance is a combined mandatory coverage offering through the Cambridge Dental & Vision Fund (CDVF).

Go here to request your dental/vision enrollment form(s).

Note that if you are a member of the Teamsters Union (with the exception of Public Works Supervisors), enrollment is not through the Benefits office. Please call 617-241-9220 for enrollment details.
Please submit your Dental/Vision insurance enrollment form within 30 days of your start date of employment.
Flexible Spending

(Coverage through EBM)
A Flexible Spending Account allows you to set aside money from your paycheck via payroll deductions, pre-tax, to pay for healthcare and dependent care expenses. You may enroll in both or either Health or Dependent Care Flexible Spending whether you are enrolled in a health plan through the City or not. Be conservative in determining the amount for which you want to enroll as any unused funds at the end of the year are forfeited.
What would you like to do with your flexible spending benefit?
Go here to request your flexible spending enrollment form(s).
Life Insurance

(Coverage through Boston Mutual)
The point of hire is your only opportunity to enroll in Life Insurance guaranteed issue through the City of Cambridge. Completion of this form is required for both enrollment and decline.
What would you like to do with your life insurance benefit?
Go here to request your life insurance form(s).
Long-Term Disability

(Coverage through Unum for Non-Union Employees; Coverage through Mutual of Omaha for Unionized Teamsters Employees)
Long-Term Disability insurance provides financial protection for you by paying you a portion of your income if you are unable to work for an extended period of time. The amount you receive is based on the amount you earned before your disability began.

Non-Union Employees – Enrollment is automatic. No action required.

Teamsters Employees – Please submit your enrollment form. Form is required for both enrollment and declination.
What would you like to do with your long-term disability benefit?
Go here to request your long-term disability enrollment or declination form(s).
Deferred Compensation

(Coverage through Empower, MetLife, and Voya)
Deferred Compensation allows you to set aside pre-tax or post-tax dollars in an account with one of our 457(b) vendors to help you save for retirement. Your contributions can be invested and have the potential to grow over time until you begin withdrawals in retirement.

Note that unlike your other benefits, you may enroll in deferred compensation at any time.
What would you like to do with your deferred compensation benefit?
Go here to request your deferred compensation enrollment form(s).

Benefits Enrollment Checklist

Health Insurance

Dental/Vision Insurance

Flexible Spending

Life Insurance

Long-Term Disability

Deferred Compensation