Human Resources > Forms > Benefits Forms

Benefits Forms

Below are forms pertaining to more than one benefit plan. For forms related to a particular benefit plan, see the link to the appropriate section.

New Employee Benefit Plan Enrollment	New employees should elect or waive health, dental and other University benefit plan coverage online using HRIS Self Service. Such selections must be made within 31 days from the hire date.
Enrollment and Policy Change Form ( PDF)	You may use this form, if you are a benefits eligible staff or faculty member who wishes to enroll, change or waive participation in the: Health plan Dental plan Vision Supplemental Term Life Basic Term Life AD&D plan Short Term Disability Long Term Disability plan This form is intended for use by currently employed faculty and staff. It is not intended for use for newly hired faculty or staff. New employees should use HRIS Self Service.
Staff Leave of Absence Provisions and Application Forms ( PDF)	This form is used to explain the leave of absence policies and for an employee to request a leave of absence.
Benefit Plan Withdrawal Form ( PDF)	Our withdrawal form can be used to drop an employee's benefits in the health, dental, life, or AD&D insurance plans as well as Contributions to the retirement plans. (Note: Reinstatement of coverage in some plans may require an Evidence of Insurability document)
Beneficiary Designation Form ( PDF)	Please contact the Benefits Division if you wish to change beneficiaries on your Basic Term and Supplemental Term policies.
Name and Address Change Form ( PDF)	This form is used to notify the Benefits Division of a change of his or her home address. Upon receipt, the Benefits Division will forward the completed form to the employee's health and dental insurance companies.
Personal Data Form ( PDF)	This form is used to notify the University of a change of home address. Upon receipt, the Payroll Division will update the HRIS payroll system records to reflect the new address
Same Gender Domestic Partner Relationship Declaration Form ( PDF)	This form is used to declare a same gender domestic partner relationship.
Same Gender Domestic Partner Relationship Termination Form ( PDF)	This form is used to terminate a same gender domestic partner relationship.
Phased Retirement Agreement Form ( PDF)	For Faculty members regarding retirement / phased retirement.