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Open Enrollment Forms 2021

Open Enrollment is Wednesday, October 20, 2021 through Wednesday, November 10, 2021. 

Health Insurance Changes or Health Insurance Waiver

Please submit any insurance changes (benefits election form and insurance enrollment form) or health insurance waivers (with acceptable proof) to HR no later than Wednesday, November 10, 2021.

Benefits Election Form

Empire Health and/or Dental Insurance Enrollment Form

Davis Vision Insurance Enrollment Form

MVP Health Insurance Enrollment Form

Sunrise Dental Insurance Enrollment Form

CSEA Health Insurance Waiver Form

CSEA Dual Health Insurance Waiver Form

Professional Health Insurance Waiver Form


Flex Spending Account - Online Enrollment

If you would like a Flex Spending account for 2022 (1/1/22 – 12/31/22), please complete the appropriate enrollment form and submit to HR no later than Wednesday, November 10, 2021. 

Flex Spending Enrollment Form CSEA/Unrepresented

Flex Spending Enrollment Form Faculty/CADA


BJs Membership

 If you would like to get a BJs membership, please mail the enrollment form and check directly to BJs by Wednesday, November 10, 2021. The contact information is on the enrollment form.

BJ's New Membership Application

BJ's Renewal Application