This form can be used to request enrollment in the Expanded LTD Plan during this year's Open Enrollment only. Open Enrollment for 2027 benefits is Monday, Oct. 12, through Friday, Oct. 23, 2026. You must submit this form by 5 p.m. Eastern Time on Oct. 23 for these elections to be active on Jan. 1, 2027.
If you wish to maintain your current level of LTD coverage, no action is required.
If you are outside of the Open Enrollment period you must use the Expanded LTD Health Statement Application for Maximum Coverage form.