Insurance Enrollment Information and Forms

Following are insurance enrollment forms and information for your employment with the City and Borough of Sitka. All links require Adobe Acrobat Reader except as indicated.

• Premera Blue Cross Plan Booklet

   Copy available in the Human Resources Office

   Check out Premera Blue Cross Premera Blue Cross website.

• Premera Blue Cross Enrollment Form

   For enrollment in the group health, dental and vision insurance program.

• Premera Blue Cross Waiver Form

   Should you not want to enrol in the group health plan.

• Premera Blue Cross Price Sheet

   Cost for various levels of insurance and basic description of current benefits.

• COBRA - Employee Notification
• HIPAA Portability/Women's Cancer Act Notice
• HIPAA Privacy Notice
• LifeWise Assurance Booklet

   Available in the Human Resources Office

   Check out LifeWise Assurance website.

• LifeWise Assurance - Basic Group Life Enrollment Form

   For Life and Accidental Death insurance provided by the City and Borough

• LifeWise Assurance - Voluntary Life Enrollment Form

   For the voluntary component of this life insurance plan. $50,000 guaranteed issue.

• LifeWise Assurance Price Sheet

   Costs for Basic and Voluntary Life Insurance

• LifeWise Beneficiary Change Form
• AFLAC/Heritage Supplemental Insurance Packets

   Available in the Human Resources Office

Mark Danielson, SPHR, Human Resources Director

(907) 747-1816  Fax: (907) 747-1846
markd@cityofsitka.com