2022 NCRGEA Open Enrollment

September 15 – October 25, 2021

Digital Form Submission

NOTE: Only elections/changes for The Standard Dental or Superior Vision may be submitted through this form. If you would like to elect for LegalShield/IDShield, you must call the call center at: 833-444-5220.

Steps to Submit:

Choose which benefit(s) you’d like to enroll or change below.
Fill out the form that appears. [It is not required that you enter a Member ID number on the enrollment form.]
Once finished, you’ll be presented with a copy to download for your reference, you’ll also receive an email confirmation.
That’s it! Once filled out it has been recieved for processing.

Online Form Submission - Enrollment

I would like to enroll or change benefits for: *

dental

vision

To enroll in or make changes to your Superior Vision elections, click the button below to fill out the form and submit.

Click to Apply for or Change Vision Coverage ONLY

To enroll in or make changes to your The Standard Dental elections, click the button below to fill out the form and submit.

Click to Apply for or Change Dental Coverage ONLY

To enroll in or make changes to all elections, click the button below to fill out the combined form and submit.

Click to Apply for or Change Dental AND Vision Coverage

To enroll in LegalShield/IDShield, this cannot be enrolled via online form. Please contact the call center at 833-444-5220 to make your elections.