Benefits Forms: Benefits Enrollment Change Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
Please Note:You have 30 days from a qualified family status change (marriage, divorce, birth, adoption, etc.) to complete and submit the Benefits Enrollment Change Form. If you do not contact the Benefits Office within this time period, you must wait until the next available Open Enrollment period to make changes to your benefits coverage. |
- Benefits
Enrollment/Change Form
- Moving Out of a Managed Care Service Area
- Dependent
Information Form
Use this form to update information for your eligible dependents already on record with the University. If you need to add eligible dependents to your benefits, please contact the HR/Payroll Service Center.
- Group
Health Insurance Application for Special Enrollment (HIPAA Special Enrollment)
- Notice of COBRA Qualifying Event
- Disabled Dependent Certification
- Stepchild
Dependency Agreement
- Application
for Principally Supported Child and Employee Certification
- Declaration
of Tax Status for Other Qualified Adult
- Health Care FSA Request for Change in Status
- Dependent Care FSA Request for Change in Status
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.