Insurance Forms

  • New Employee Benefit Enrollment Form For employees about to be hired, just hired or newly eligible for benefits by virtue of a position change. Should be completed on or before the employee’s hire date, but may be completed within 60 days of hire or benefit eligibility. Employee may also need to complete a Dependent Enrollment/Change Form and designate beneficiaries. Must be returned to employee’s Human Resources office. (HR 100  7/16)
  • ACA Employee Enrollment Form for employees newly eligible for benefits as a result working 75% effort or more during their measurement period. Employee may also wish to complete a Dependent Enrollment/Change Form. Must be returned to employee’s Human Resources office. (HR 99  07/16)
  • Benefit Change Form Used to make changes to an employee’s/retiree’s benefits. To change health or dental coverage or Flexible Spending Account deductions, this form MUST be completed within 60 days of employment or eligibility for benefits or within 60 days of a Change in Status. (HR 105  11/16)
  • Retiree Benefit Enrollment Form Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage. (HR 107  04/16)