Instructions and Important Reminders: 

Complete the “APS Benefits Enrollment and Change Form” indicating your coverage elections and/or waivers and return your completed form to the Human Resources Department. (see contact information at bottom of form)

Electing Medical, Dental, Vision, Voluntary Disability Buy‐Up (if eligible), Health Care FSA, and Dependent Care FSA 

• NEW Employee:  Coverage will begin on the 1st day of the month following 30‐days of employment. You have 31‐days from your first day of employment to elect coverage. 

• NEWLY‐Eligible Employee:  Coverage will begin on the 1st day of the month following the effective date of your new, benefits‐eligible position.  You have 31‐days from your new, benefits‐eligible position to elect coverage. 

Electing Parking FSA and Transit FSA  You can enroll or change your Parking and Transit FSA elections at any time during the year.  Elections are effective the pay period following your election or change request. 

Waiving Coverage  If you decide not to enroll in coverage, you must complete the “APS Benefits Enrollment and Change Form.”  Select the “Waive” boxes and return your completed form to Human Resources. 

Electing Coverage for Eligible Dependents: 

Your eligible dependents can also participate in the plans in which you are enrolled:

• Your lawful spouse: your spouse is eligible to participate in the plan if he or she is an individual who is recognized as your husband or wife under the laws of the state where you live. (Common‐law spouses are not eligible.) If covering a spouse, you will need to provide a copy of your marriage certificate. 

• Your child(ren): including your biological child, legally‐adopted child (or child placed for adoption), stepchild, foster child, child for whom you are the legal guardian and child you are required to cover under the terms of a qualified medical child support order, to age 26. If covering a dependent child, you will need to provide a copy of your child’s birth certificate, or proof of adoption or legal guardianship.

If you are enrolling your eligible family members for benefits, you will need to provide your dependent’s full name, date of birth, gender, and Social Security number.