Benefits Enrollment/Change Form for Retirees

Purpose

This form allows for retirees to either enroll in a benefits program or change their current benefits enrollment program.

NOTE: This form must be submitted within 31 days of your date of eligibility or qualifying life event. 

Last updated: 5/18/2020

Download a form below and open in Adobe Acrobat. Forms can be submitted electronically or printed and mailed/faxed to Employee Services.