Leave blank for insurance taken after taxes are deducted. This date must be at least one year later than the originaL hire date. A DU form must also be completed. A DU form must also be completed. Date WILL change if there is a change between State and CU plans, or vice- versa.
Date is left blank if canceled or waived.
If the employee is enrolled in a State of Colorado dental plan, include children under age 5 as dental dependents, even though there is no charge for them. A DU form must also be completed. Use if change is from State to CU, or vice-versa. Indicate amount of life insurance paid out as benefit. You may use 30 characters.