Benefits Enrollment/Change Form for Faculty, Officers and University Staff

Purpose

 This form allows faculty, officers and university staff to either enroll in benefit programs or change current benefit programs.

NOTE: This form 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.