enrollment forms

To enroll in benefits, newly eligible employees must complete a Benefits Enrollment Worksheet and submit it to Benefits Services via the Benefits Services Secure Dropbox or in Welch Hall 340 within 60 days of the effective date of their qualifying appointment.

If an employee submits the completed worksheet by the last business day of their hire month, coverage may begin on the first day of the following month.

Once an employee submits their worksheets (within the 60 days) coverage will always begin the first day of the following month.

The coverage effective date will be delayed if the Benefits Enrollment Worksheet and all necessary enrollment documents are not submitted in a timely manner.

Note: If you miss the initial 60-day enrollment period, you can still enroll but your coverage will not be effective until the first day of the month following a 90-day waiting period.

• ACA Benefits Enrollment Forms
• Benefits Enrollment Worksheet
• Health Care /Dependent Care Reimbursement Account Enrollment Form
• VSP Premier Enrollment Form

METHOD OF SUBMISSION

All forms must be completed and submitted to Benefits Services through the secure file transmission DropBox.

Please submit all forms to Benefits Services via the Benefits Services Secure Dropbox or in Welch Hall 340.

General questions can be e-mailed to benefitservices@lefoudy.com.