Forms
Available Benefits Forms
Choose a link below to print a benefits form. These forms are 508 compliant and may be filled out online and printed. If you have the Adobe tools you can even save these forms with your information.
Plan Year 2023 (January - December) Forms
- 2023 Employees Benefits Department Exclusion for Spouse Coverage Form
- 2023 Employees Benefits Department Employee Opt-Out Acceptance Form
- 2023 Employees Benefits Department Newly Eligible Form
- 2023 Employees Benefits Department Dependent Attachment Form (for additional dependents)
- 2023 Employee Benefits Department State Employee Decrease Supplemental Life Insurance
- 2023 Employees Benefits Department Request for Coverage for Common-Law Spouse
- 2023 HCM Employees Benefits Department Change Request Form
- 2023 EBD State Employee Application for coverage for Other Dependent Children
- 2023 Disabled Dependent Assessment
- 2023 Application – Individual
- 2023 HealthChoice Life Insurance Application Option Period/Midyear Change
- 2023 Life Insurance Application New Hire Rehire
Plan Year 2022 (January - December) Forms
- 2020 Employees Benefits Department Dependent Attachment Form (for additional dependents)
- 2020 Employees Benefits Department Employee Opt-Out Acceptance Form
- 2020 Employees Benefits Department Exclusion for Spouse Coverage Form
- 2020 Employees Benefits Department Newly Eligible Form
- 2020 Employees Benefits Department Request for Coverage for Common-Law Spouse
- Application – Individual
- COBRA Qualifying Event Notice
- EBD Benefits Coordinator Appointments Form
- EBD Plan Year 2021 Option Period Enrollment Form
- EBD State Employee Application for coverage for Other Dependent Children
- Employee Benefits Department State Employee Decrease Supplemental Life Insurance
- Employees Benefits Department 2020 HIPAA Certificate Request Form
- HCM Employees Benefits Department Change Request Form
- Life Insurance Application - Option Period/Midyear coverage
- Life Insurance Application New Hire Rehire
Last Modified on
Oct 04, 2022