EBO Forms

Health and Dental - Active Employees

• 2008 Health Plan Election/Change Form Instructions + Rates (new for 2008)
• 2008 Health Plan Election/change Form (new for 2008)
• New Enrollee Health Plan Election/Change Form Instructions + Rates
• New Enrollee Dental Plan Election/Change Form Instructions
• Dental Plan Election/Change Form
• Dental Plan Election/Change Form (use for Open Enrollment only)
• Change Form (name and address)
• Student Verification Form
• Dependent Certification Affidavit -- use only during Annual Enrollment and New Hire
• Deletion of Dependent(s)
• Blue Shield High Deductible Non-Network Claim Form
• Health Plan Waiver Form
• Conversion to Tier B Form - use only if you're electing to convert from Tier A to Tier B (no other changes)

Health Savings Account

• Wells Fargo HSA Enrollment Form - return completed form to the Employee Benefits Office
• Health Savings Account Election Change Form – return completed form to the Employee Benefits Office
• Health Savings Account Reimbursement Request Form - Wells Fargo

Life Insurance

• Enrollment/Beneficiary Change Form (new for 2008)
• New Enrollee Enrollment/Beneficiary Change Form Instructions
• Enrollment/Beneficiary Change Form (2007)
• Evidence of Insurability Instructions and Application Form (Proof of Good Health Form) – must complete this along with an Enrollment/Beneficiary Change Form.  Please submit forms back to Employee Benefits Office by fax or by mail.   

Flexible Spending Account

• Flexible Enrollment Form (new for 2008)
• Flexible Enrollment Form (2007)
• Flexible Spending Mid-Year Change Form
• Flexible Spending Claim Form (new for 2008)
• Flexible Spending Claim Form (2007)
• Dependent Care Contract Form
• Orthodontia Contract Form
• Flexible Spending Direct Deposit Authorization Form
• Medical Reimbursement Account Worksheet
• Dependent Care Reimbursement Account Worksheet

Deferred Compensation

• Please see Deferred Compensation website for forms.

Inquire about the availability of documents in alternate formats.