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City of
Rockingham

Complete this form to enroll in or change your voluntary benefits for this upcoming year.

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For July 1, 2026 Open Enrollment Only 

Effective July 1, 2026

Benefit Options

Enroll in The Standard's Accident Policy?
Who would you like to enroll in The Standard's Accident Policy?
Which Accident Policy?
Enroll in The Standard Cancer Policy?
Who would you like to enroll in The Standard's Cancer Policy?
Which Cancer Policy?
Who would you like to enroll in Allstate Universal Life Coverage?
Child 1 Gender
Child 2 Gender
Child 3 Gender
Child 4 Gender
Enroll in Short Term Disability Policy?
Enroll in Guardian Criticall Illness?
Enroll Spouse/Domestic Partner in Guardian Criticall Illness? (Coverage = 50% of EE)
Enroll Child(ren) in Guardian Criticall Illness? (Coverage = 25% of EE)
Employee Gender
Spouse/Domestic Partner Gender
Child 1 Gender
Child 2 Gender
Child 3 Gender

Thanks for submitting! If we have any additional questions, we will contact you directly!

Eastern Select Services

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