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Open Enrollment Forms


Please complete the applicable form for your Open Enrollment changes. Changes will be effective 1/1/2023. You may print the form and fax it to Human Resources at 218.249.6094. Or you may fill in the PDF, save the form, and email the form to EmployeeBenefits@slhduluth.com.

Forms must be received in Human Resources no later than November 11, 2022. There are no exceptions to this deadline.

ENROLL

Medical Insurance
If you would like to enroll in St. Luke’s medical insurance for the first time, complete the applicable enrollment form. See the Open Enrollment Hub for the Medical Plan Comparison which provides details on the medical insurance plans.

Advantage Plan Open Enrollment Form

Balanced Plan Open Enrollment Form

Dental Insurance
If you would like to enroll in St. Luke’s dental insurance for the first time, complete the following form.

Dental Insurance Open Enrollment Form

Flexible Spending Account
Flexible Spending Account (FSA) elections do not roll over; you must actively elect contributions each year. Complete the following form to elect the FSA for 2023.

Flex Open Enrollment Form

MAKE CHANGES

Medical Insurance
If you would like to add or delete dependents on your medical insurance or would like to change medical insurance plans, complete the following form.

Medical Insurance Open Enrollment Change Form

Health Savings Account
Your Health Savings Account (HSA) contributions will continue until you change them. Complete the following form if you would like to change your contribution amount.

HSA Open Enrollment Contribution Change Form

Dental Insurance
If you would like to add or delete dependents on your dental insurance, complete the following form.

Dental Insurance Open Enrollment Change Form