Add/Remove Coverage or Dependents
You will need to complete a Health Benefits Change form if you wish to add/remove dependent(s) from your health plans. Supporting documentation will be required. A completed Health Benefits change form must be received by Health and Wellness within 30 days of a permitting event, unless otherwise noted in the Health Benefits Eligibility Policy.
You will need to complete a Health Benefits Enrollment Form if you wish to add coverage or a Health Benefits Declination Form if you wish to remove coverage. Supporting documentation will be required. The completed form must be received by Health and Wellness within 30 days of a permitting event, unless otherwise noted in the Health Benefits Eligibility Policy.
Important Notes
- You must have an account for the online forms platform in order to submit a form. Create an account
- As of January 2021, the enrollment forms no longer work with Internet Explorer. If you do not have another browser installed on your work PC, you can fill out a form from your home PC, smart phone, or tablet.
- If you have questions about how to fill out the below forms, see the Health Benefits Online Forms FAQ.
Health Benefits Change Form for Extra-Help/Temporary Employees
Health Benefits Enrollment Form for Extra-Help/Temporary Employees
Health Benefits Declination Form for Extra-Help/Temporary Employees
