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 (HSA)

• For 2025 - Flexible spending account enrollment form
• For 2026 - Flexible spending account enrollment form

Health Plan PPO 

• PPO Health insurance enrollment and change form (complete electronically)
• PPO Health insurance enrollment and change form (print to complete)

Health Plan HMO 

• HMO Health Assessment instructions
• 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 (Employee)

• Life insurance enrollment and change form, employee (complete electronically)
• Life insurance enrollment and change form, employee (print to complete)

Life Insurance Dependent (Spouse and Child)

For staff compensation system employees, coaches, and research staff (R4, R5, and R6 only).

• Life insurance enrollment and change form, dependent (complete electronically)
• Life insurance enrollment and change form, dependent (print to complete)

Long-term Disability Insurance 

• 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)
• Tuition remission application, academic year 2025-26 (complete electronically)
• Tuition remission application, academic year 2025-26 (print to complete)