Page 17 - Dentons 2021 Benefits Guide Retiree

2021 Open Enrollment Benefits Election Form
(Retirees)

Please return your completed election form by November 20, 2020 to continue your Retiree coverage for
the 2021 plan year. This form can be emailed to jessica.hoyt@dentons.com or mailed to:
Dentons US LLP, 233 S. Wacker Drive, Suite 5900, Chicago, IL 60606, Attn: Jessica Hoyt
Participant Information

Name: Social Security #:

Address: Date of Birth:

Email: Phone #:
2021 Coverage- check box below if your coverage will remain the same

 No changes to my 2021 insurance coverage
Medical Coverage Changes - check box below to make changes to your 202 1 medical coverage
BCBS of IL Medical Plans: Coverage Level:
□ BCBS of IL CDHP 3000 Medical Plan □ Self
□ BCBS of IL CDHP 1500 Medical Plan □ Self + 1
□ BCBS of IL PPO 1200 Medical Plan □ Family
□ I decline medical coverage
Dental Coverage Changes - check box below to make changes to your 202 1 dental coverage
MetLife Dental Pl ans: Coverage Level:
□ MetLife Basic Dental Plan □ Self
□ MetLife Enhanced Dental Plan □ Self + 1
□ Family
□ I decline dental coverage
Vision Coverage Changes- check box below to make changes to your 202 1 vision coverage

VSP Vision Plan: Coverage Level:
□ I elect vision coverage □ Self
□ Self + 1
□ Family
□ I decline vision coverage

Eligible Dependent Information
Social Security Date of Assign
Name (Last, First, MI) Gender Number Birth Relationship coverage for:
□ Medical
□ Dental
□ Vision
□ Medical
□ Dental
□ Vision
Authorization
By signing below, I certify that I satisfy the criteria for coverage established under the Dentons US Retiree Benefits policy . I understand that my elections are irre vocable until
the next open enrollment period, unless I have a qualifying status change as defined by the Federal Internal Revenue Code. I understand that I must request changes within 31
calendar days of the qualifying status change. I also understand t hat any perso n who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in a state prison.
_______________________________________________ ______________________
Signature Date