Benefits Enrollment Forms

Your online Benefits Enrollment packets are available for you upon hire or transfer into a benefitted position. You are presented with a packet of benefits information (health plan enrollment, supplemental life insurance options, and other misc plans, i.e, Guardian, etc). UMC offers two health plan options: Clark County Self Funded (PPO) and Exclusive Provider Organization (EPO). Health and Life Benefits consists of the following:

If you are on the M-Plan, please contact your benefit representative for rate information.

You must sign up for your health insurance no later than two weeks before it takes effect (ex: effective date 6/1 - sign up before 5/15). Bring all appropriate documentation (certified marriage certificate, children's birth certificate, social security numbers, etc).

If you elect to pre-tax your health insurance payroll deduction you cannot delete/drop a dependent unless you have a "qualifying event" (divorce, eligibility of other coverage, etc). However, It is important that you speak to a benefit representative if these events occur in order to assist you with your change.

Benefits Processing Location:
UMC Human Resources Office
Delta Point Building
901 Rancho Lane, Ste. 195
Las Vegas, NV 89106

Click for Map and Directions

Click the appropriate cover page below to download each packet
Use the toolbar buttons at the top of the PDF document screen to fillout, print, and save
Packets are informational only. Forms must be completed in full and returned to Human Resources
Clark County Self Funded (PPO) Exclusive Provider Organization (EPO)

Benefit Enrollment Form

Clark County Self Funded 2021 Plan Document

CCSF Plan Description

Self Funded Medical Provider Directory through SHO

Self Funded Dental Provider Directory through Diversified

2021 Clark County Spousal Inquiry Letter

2021 Clark County Summary of Benefits and Coverage (SBC)

EyeMed info - vision plan for Self Funded participants

Self Funded Change Form

2021 CCSF Wellness Benefits Claim Form

Navitus Open Enrollment Flier

Mail Order Costco

Life Insurance/Summary of Coverage:

Sun Life Voluntary Group Term Life Benefit Highlight

Sun Life Voluntary Life Insurance Rates

Sun Life Voluntary Accidental Death and Dismemberment (AD&D) – Benefit Highlight

Sun Life Voluntary Accidental Death and Dismemberment (AD&D) Insurance Rates

Sun Life Group Enrollment Form
fillable form which can then be printed and then must be returned to benefits upon completion for further processing

Sun Life Evidence of Insurability (EOI) Process When Applying for Voluntary Group Term Life Insurance

Sun Life Beneficiary Form
print form and return to benefits upon completion for further processing

Sun Life Emergency Travel Assistance and Identity Theft Protection

Additional Resources:


2020 Dependent Child Guarantor Affidavidt Form (Self Funded and HPN)

TASC Card Experience

TASC Dependent Care FSA Qualifications


TASC Mobile Experience

Guardian Information

EPO 2022 Plan Document

EPO Co-Pay Grid

2022 EPO Summary of Benefits and Coverage (SBC)

EPO Dental Providers SHO

EPO Dental Summary

EPO Vision Benefits

EPO Medical Provider Directory

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whether express or implied, regarding the accuracy of the translation provided above.