City of Burlington, Vermont City of Burlington, Vermont

200 Church Street, Suite 102 
Burlington, VT 05401
Phone: 802-865-7145 Fax: 802-864-1777

 

Open Enrollment

We are fortunate to have a two opportunities to assess our current healthcare needs for ourselves and/or our families. Open enrollment allows us to re-examine our medical and dental plans, our life insurance plans, our retirement benefit (457 plans) and finally, a gym membership. Below you will find the necessary forms to complete your enrollment process.

  • Medical Enrollment/Change Form - GISC: click here
  • Dental Enrollment/Change Form - Delta: click here
  • Domestic Partner Affidavit Form: click here
  • Domestic Partner Taxation Memo: click here
  • FSA (Flexible Spending Account) Enrollment Form:  click here
  • Supplemental Life Insurance - Enrollment Form - Standard Insurance Co: click here
  • Life Insurance Beneficiary Change Form - Standard Insurance Co: click here
  • Supplemental Life Insurance - Medical History Statement - Standard Insurance Co: click here
  • Retirement Programs: 457 Deferred Compensation Plans
    • ICMA-RC please contact Michael Savage, 1-888-803-2721
    • Nationwide, please contact Paul Bertand, 1-877-677-3678
  • Gym Memberships - Rate Sheet: click here
  • Gym Membership Payroll Deduction Agreement: click here
  • Gym enrollment forms and additional information regarding gym memberships can be found on our Discounted Gym Membership page.