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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, 2025 Open Enrollment Only 

Effective July 1, 2025

Benefit Options

Enroll in Allstate Accident Policy?
Who would you like to enroll in Allstate's Accident Policy?
Which Allstate Accident Policy?
Enroll in Allstate Cancer Policy?
Who would you like to enroll in Allstate's Cancer Policy?
Which Allstate 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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