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.
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.
- Beneficiary Update/Change
- Moving Out of a Managed Care Service Area
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.
Health Insurance Application for Special Enrollment (HIPAA Special Enrollment)
- Notice of COBRA Qualifying Event
- Disabled Dependent Certification
for Principally Supported Child and Employee Certification
of Tax Status for Other Qualified Adult
- Health Care FSA Request for Change in Status
- Dependent Care FSA Request for Change in Status