Open Enrollment for Employees on Leave

A tobacco surcharge is applicable to Employees covered by the Health Protection Plan who use tobacco products, and/or have dependent(s) covered by the Plan that use tobacco products. Employees that do not use tobacco products and whose covered dependent(s) do not use tobacco products will not be subject to the surcharge. For the purposes of the surcharge, the term "tobacco products" includes but is not limited to cigarettes, snuff/smokeless tobacco, pipes, cigars and any other type of tobacco or smokeless tobacco product and e-cigarettes.

Tobacco User(s): You are attesting, to the best of your knowledge, that you and/or a covered dependent(s) are using tobacco products.

Non-Tobacco User(s): You are attesting, to the best of your knowledge, that you and all covered dependent(s) do not use tobacco products and have not used tobacco products in the past 90 days, and you agree to notify ERIE's Benefits Operations and Planning Section in accordance with the program guidelines if your tobacco user status, or that of an enrolled dependent, changes.

Waiving Medical Coverage: If you are waiving medical coverage, ERIE does not require you to state whether or not you are a tobacco user.

An additional $50/month surcharge applies to all Health Protection Plan coverage options for tobacco users. The tobacco surcharge applies if you or any of your covered dependents are tobacco users. You may discontinue the surcharge after completion of our reasonable alternative program through UnitedHealthcare.  Please contact Benefits using the HR Helpline at (814) 870-3747 for more information. 

By attesting the tobacco use status for you and your covered dependent(s), you are completing an official record relating to your employment benefits and you are required to be truthful and accurate in your representation.

You must be actively at work to enroll or re-enroll in the Health Care Flexible Spending Account or Dependent Care Flexible Spending Account and to make a change to the Critical Illness, Supplemental Group Life Insurance, the Accidental Death & Dismemberment, or the Dependent Life Insurance. Contact Benefits using the HR Helpline at (814) 870-3747 within 31 days upon your return to work to make changes or enroll.
 

I authorize the benefit elections noted below and any related payroll deductions. I understand my Benefit Plan elections are effective January 1, 2026, through December 31, 2026, and cannot be revoked or changed during the plan year unless they are consistent with a qualifying change in status as defined in the plan descriptions.