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City of
Rockingham

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

For July 1, 2024 Open Enrollment Only 

Effective July 1, 2024

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?
Enroll in Principal Term Life Policy? (New EE GI 100K)
Enroll Spouse in Principal Term Life Policy? (New EE Spouse GI 25K)
Enroll Child in Principal Term Life Policy?
Who would you like to enroll in Allstate Universal Life Coverage?
Child 1 Gender
Child 2 Gender
Child 3 Gender
Child 4 Gender
Who would you like to enroll in Principal's Dental Policy?
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!

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