Are you an active employee wanting to make plan changes?

Select the correct form(s) for your bargaining unit (Management, Union Group, etc.) from the list below.

Complete all sections of the form(s).
Return the form(s) to Employee Benefits within 90 days of the triggering event.
Your newborn child** needs to be enrolled within 90 days of birth. Failure to properly enroll will mean you cannot enroll the child until the next annual open enrollment.
A child newly placed for adoption* needs to be enrolled within 90 days of placement. Failure to properly enroll will mean you cannot enroll the child until the next annual open enrollment.

*Copies of legal documents required
**Newborn grandchild, born to your existing eligible, enrolled dependent, MUST be enrolled within 90 days of birth or they WILL NOT be covered and WILL NOT be eligible to be added during the next open enrollment, unless you have obtained legal custody of grandchild.

You must notify employee benefits of a dependent who is no longer eligible to be covered on your medical and dental plans within 90 days of their loss of eligibility. 

Your change form must be received by the benefits office within 60 days of the event causing loss of eligibility in order to be eligible for a COBRA continuation offer.

If you are deleting a spouse or domestic partner due to divorce or termination of domestic partnership, you must complete and return a Statement of Termination of Marriage or Domestic Partnership.