Namely Open Enrollment Form

1
Company Name* This field is required.
2
Main Contact* This field is required.
First Name
Last Name
3
Main Contact Email* This field is required.A copy of your responses will be automatically sent to the email provided here.
example@example.com
4
EINs and Active Benefit Eligible Classes* This field is required.Include ALL EINs and benefits eligible classes that will be participating in this upcoming Open Enrollment per EIN.
5
Are non-spouse Domestic Partners covered?* This field is required.
YESNO
6
Are Domestic Partner children eligible to enroll?* This field is required.
YESNO
7
What type of Domestic Partners are covered?* This field is required.
Please Select
Please Select
Opposite Sex only
Opposite Sex and Same Sex Partners
8
When do benefits end for a child once they are over age?* This field is required.
Please Select
Please Select
Date of Birth
Day Before Birth Date
End of Birth Month
End of Plan Year
Not Applicable
9
Are there any active plans that will be terminated?(Plans that will not be offered in the upcoming plan year)
YESNO
10
If yes, please enter the specific plan name as it appears in the Namely system and end date for any plans that will no longer be offered* This field is required.
11
Will any Existing plans continue to be offered?* This field is required.
YESNO
12
Existing Plan Details* This field is required.Enter any Existing Plans that will continue to be offered during open enrollment.
13
Upload Plan Summary documents for any existing plans:* This field is required.Please ensure each file name contains plan name
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Upload plan rates for any existing plans* This field is required.Include Employee and Employer Monthly Costs for ALL Existing plans that will continue to be offered
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Will any new plans be offered?* This field is required.
YESNO
16
If yes, enter any new plans that will be offered during open enrollment* This field is required.Scroll to the right to ensure all required fields are completed. If you select “Other” for the Waiting Period or Termination Period, you’ll be asked to provide additional details in the next question.
17
Additional Waiting Period/Termination Period Details (if “Other” was selected)If you selected “Other” for the Waiting Period and/or Termination Period for any plan in the previous question, please provide the additional details below.
18
Upload Plan Summary documents for any new plans:* This field is required.Please ensure each file name contains plan name
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Upload plan rates for any new plans* This field is required.Include Employee and Employer Monthly Costs for ALL Existing plans that will continue to be offered
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Acknowledgement
By signing below, I affirm that the information provided in this form is complete, accurate, and truthful to the best of my knowledge. I acknowledge my responsibility to promptly notify Namely of any changes to this information. Furthermore, I understand that maintaining accurate and up-to-date information is essential for the effective processing and management of my records.

Signature *
First Name *     Last Name *
Date *
Should be Empty: