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: 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.