Forms: Benefit Enrollment and Changes
Designated Eligible Individual
- Designated eligible individual enrollment form (complete electronically)
- Designated eligible individual enrollment form (print to complete)
Flexible spending account, hsa Bank
- For 2024 - Flexible spending account enrollment form
Health Plan PPO enrollment and changes
- PPO Health insurance enrollment and change form (complete electronically)
- PPO Health insurance enrollment and change form (print to complete)
Health plan HMO enrollment and changes
- HMO Health insurance enrollment and change form (complete electronically)
- HMO Health insurance enrollment and change form (print to complete)
- HMO Qualification Form with Instructions (print to complete)
- HMO Primary Care Physician Selection form (complete electronically)
- HMO Primary Care Physician Selection form (print to complete)
Life insurance enrollment and change form, employee
- Life insurance enrollment and change form, employee (complete electronically)
- Life insurance enrollment and change form, employee (print to complete)
Life insurance enrollment and change form, dependent
For staff compensation system employees, coaches, and research staff (R1 and R2).
- Life insurance enrollment and change form, dependent (complete electronically)
- Life insurance enrollment and change form, dependent (print to complete)
Long-term disability insurance enrollment and change form
- Long-term disability insurance enrollment and change form (complete electronically)
- Long-term disability insurance enrollment and change form (print to complete)
Tuition remission application
For spouse and dependent program.
- Tuition remission application, academic year 2024-25 (complete electronically)
- Tuition remission application, academic year 2024-25 (print to complete)