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
• For 2025 - 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 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 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 (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 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)