Benefits Enrollment Forms

OPEN ENROLLMENT IS MONDAY, NOVEMBER 2, 2020 THROUGH WEDNESDAY, NOVEMBER 18, 2020


Please submit any insurance changes (with acceptable proof as needed) to the Benefits Office at Town Hall no later than Wednesday, November 18, 2020.  All changes will be effective January 1, 2021.

Select the enrollment/change forms that you need from the options below:

Blue Cross

Enrollment Form - Blue Cross PPO & Network Blue New England Plans

Mail Order Prescription Enrollment Form
This service provides you with a 90-day supply of your maintenance medications delivered to your home, for the cost of a 30-day copay


Harvard Pilgrim

Enrollment Form - Harvard Pilgrim Best Buy & HSA Plans

HSA Contribution Form
The 2021 annual limit on HSA contributions will be $3,600 for self-only and $7,200 for family coverage (this includes the Town's contribution of 1/2 of your deductible).  Those age 55+ can contribute an additional $1,000 annually.

Mail Order Prescription Enrollment Form
This service provides you with a 90-day supply of your maintenance medications delivered to your home, for the cost of a 30-day copay 


Altus Dental

Altus Dental Enrollment Form


Benefit Strategies - Flex Spending

Flexible Spending Account Enrollment Form
The 2021 annual limit on FSA contributions will be $2,600 for healthcare expenses and $5,000 for dependent care expenses.  The minimum amount for both is $250.

Claim Form for Medical and Dependent Care Expenses


BurlingtonScripts

If your brand name maintenance medication is on the following lists you can receive it for free through mail order:

BurlingtonScripts Enrollment Package - Harvard Pilgrim

BurlingtonScripts Enrollment Package - Blue Cross


Hartford Life Insurance

Hartford Enrollment Form
Guaranteed enrollment limits are $120,000 for employees, $20,000 for spouses, and $10,000 for children.  If you would like a higher amount of coverage you will need to complete the Evidence of Insurability form below.

Hartford Evidence of Insurability Form
If you are electing coverage above the guaranteed maximum, this form will need to be completed and attached to your application


Prudential Life Insurance (NCPERS)

NCPERS Enrollment Form
This plan is only available to those enrolled in the Middlesex County Retirement System


Lincoln Financial - Short & Long Term Disability

Lincoln Enrollment Form - Short & Long Term Disability
Open enrollment does not include disability insurance, but you may elect coverage at this time.  You will need to complete and attach the Evidence of Insurability form below with your application.

Lincoln Evidence of Insurability Form
This form must be included with your application


Deferred Compensation - 457 Plans

Contribution limits will stay the same at $19,500 in 2021.  If you are age 50 or over, the catch-up contribution limit will also stay the same at $6,500.  Employees taking advantage of the special pre-retirement catch-up may be eligible to contribute up to double the normal limit, for a total of $39,000.

SMART Plan Enrollment Form
For enrollment in the Traditional or Roth 457 plan with Empower Retirement

ICMA-RC Enrollment Form
For enrollment in the Traditional or Roth 457 plan with ICMA-RC.  Burlington's plan number is 303313.

Nationwide Enrollment Form
For enrollment in the Traditional 457 plan with Nationwide