Forms: Long Term Care

Below are enrollment forms for the Long Term Care plan sponsored by the CNA insurance company. The Benefits Division will accept original enrollment forms or applications. Copies, faxes and .pdf files will not be accepted.

Initial Benefits Eligibility.  At hire or initial eligibility, coverage is automatically approved for faculty and staff provided the Benefits Division receives completed enrollment forms within 31 days of initial eligibility. A spouse of other eligible family member must apply for coverage by completing a questionnaire which asks a few medical history questions. The completed questionnaire must be received by the Benefits Division within 31 days of the employee's date of hire or initial benefits eligibility. Upon receipt, it will be forwarded to CNA for their review and approval or disapproval.

After Initial Benefits Eligibility. An employee may apply for Long Term Care coverage by completing the enrollment process during Open Enrollment or within 31 days of a qualifying change in family or employment status. Applications are subject to the approval of CNA.

Newly eligible faculty & staff may conviently elect to or waive healthcare coverage using the eBenefits, HRIS Self Service module.
Application for Retirees ( PDF)	This form should be completed by retirees and returned to the Benefits Division.
Application for Faculty and Staff ( PDF)	This form should be used by new faculty and staff and must be received by the Benefits Division within 31 days from the date of hire or benefits eligibility.