PO Box 1095 Kirksville, MO 63501 cva@charitonvalley.org Phone: 660-665-1111 Fax: 660-665-1409 HR Fax: 660-665-3417

Plan changes/New Enrollments

If you wish to make plan changes or are a new employee signing up for benefits for the first time, please complete the forms below and return to the HR office no later than 30 days of your qualifying event date.

**Note, there is a 2 month calendar wait for benefits to begin. Example: If you were hired/promoted to Full-Time status 6-15-20, your effective date of coverage is 9-1-20.**

Anthem Enrollment Application (Complete all sections. If declining coverage, complete section 11)

Payroll Election Form (Hourly Employee 24 pay periods)

Payroll Election Form (Admin Exempt Employees 12 pay periods)

FSA Participation Form (If you selected one of the Copay 1500/2500 PPO Health Plans)

HSA Participation Form (Hourly Employees 24 pay periods) If you selected the 2500 High Deducible Health Plan

HSA Participation Form (Admin Exempt Employees 12 pay periods) If you selected the 2500 High Deducible Health Plan

Anthem Optional Life Insurance Application (To be completed if you are making changes to your life insurance coverages)

Supplemental Insurance Options

Supplemental Insurance
Aflac logo
Supplemental Insurance Plan options for all employees including:
-Additional term life insurance
-Cancer Policy
-Accident Policy
-Critical Care and Protection
-Short-Term Disability

Contact our agent below to enroll in Aflac benefits:
Desaray Wilhite Business Card

legal shield logo
All employees are eligible to sign up for this service.
Provides protection against identity theft for individuals or families.
Legal Shield attorneys available for consultation on legal, financial, and family matters.
Please see the LegalShield flyers for more information
Rich Ellerman Business Card


Please return these forms to Curtis Mason in HR via email at cmason@charitonvalley.org, or fax to 660-665-1409, or in person at the Business Office.

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