Benefits Enrollment/Change Form for Retirees
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: 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.