Benefits Enrollment/Change Form for Classified Staff

Purpose

 This form allows classified staff to either enroll in a benefits program or change a current benefits program.

NOTE: Any necessary paperwork and documentation must be submitted within 31 days of your date of eligibility or qualifying life event and by the 10th of the month in order to start on that month's paycheck.

Last updated: 4/16/2019  

 

Download this form below. We recommend using Internet Explorer or Firefox browsers. If you are unable to open the fillable form a non-fillable version has been provided. Then either fax or mail the completed form to Employee Services.