Enrollment Forms

Benefits Enrollment/Change Form

Must be submitted to the Human Resource Office MSR 320 within the 60-day enrollment window, your benefits will begin the first of the month following the date your paperwork is received in HR. If paperwork is received in HR after the 60-day window, a 90 day waiting period is required. (Faculty starting in the Fall are eligible for benefit coverage effective October 1. Faculty starting in the Spring are eligible for benefit coverage effective March 1.)

• Health Benefits Enrollment/Change Form (Printable)
• Health Benefits Enrollment/Change Form (E-Fillable)

This form can be used for the following:

• New Employee
• Add/Remove Spouse
• Add/Remove Dependent
• Enroll in Flex Cash
• Open Enrollment (when applicable)

Qualifying Events

Enrollment form with supporting documentation must be submitted to the Human Resource Office MSR 320 within the 60-days of the qualifying event, the change will be effective the first of the month following the date your paperwork is received in HR. If paperwork is received in HR after the 60-day window, a 90 day waiting period is required.

Types of Qualifying Events:

• Loss of outside coverage
• Marriage
• Domestic Partnership 
• Divorce*
• Birth or adoption** 
• Move to new service area

*effective date is the 1st day of the month following the event date.

**Newborn infants are eligible for health coverage from and after the moment of birth. Adopted children are eligible for health coverage from and after the moment the child is placed in the physical custody of the eligible employee for adoption.

Flex Cash

If you have group medical and/or dental coverage outside of the CSU, the Flex Cash Plan pays you to cash in lieu of CSU coverage.  Under this plan, the Flex Cash medical benefit is $128 per month and the dental benefit is $12 per month.  To enroll in this benefit you must complete the Flex Cash portion of the above benefits form and provide proof of medical and/or dental coverage. We MUST receive your enrollment by the 3rd of the month for your Flex Cash to be effective the 1st of the next month.

VSP Premier- Voluntary Upgrade Plan

For more information about this voluntary benefit, please visit the Voluntary benefit page.
Enrollment Form

Health/Dependent Care Reimbursement Account (HCRA/DCRA)

For more information about this voluntary benefit, please visit the Voluntary benefit page.

2023 HCRA/DCRA Enrollment Form

ScholarShare

For more information about this voluntary benefit, please visit the Voluntary benefit page.
Enrollment Form