Benefits Enrollment/Change Form

IMPORTANT—READ FIRST

    • You have 31 days from your date of benefits eligibility or qualifying life event to complete the enrollment/change form.
    • If enrolling any dependents in medical, dental, optional life, and/or voluntary AD&D plans, you must attach the required documents as listed on the Employee Services website to demonstrate dependent eligibility. Your dependents will not be enrolled in benefits if the correct documents are not attached.
    • The form must be legible, each section must be completed in its entirety, and all necessary documentation must be attached.
    • Incomplete and incorrect forms will not be processed. Consequently, your benefits could be delayed or you could risk losing enrollment eligibility for certain benefits.

Benefits Enrollment/Change Forms


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