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