Benefits Enrollment/Change Form for Surviving Spouse

Purpose

 This form allows a surviving spouse/partner 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.

Last updated: 4/16/2019

 

Download this form below. We recommend using Internet Explorer or Firefox browsers. Then either fax or mail the completed form to Employee Services.