Benefits Enrollment Change Form printable pdf download

2016 Benefits Enrollment/Change Form

Enrollment Instructions

Step 1: Complete the form fully and legibly.

If you have more dependents than form space allows, attach an additional page.

If evidence of good health and underwriting approval are required for Aetna life insurance, Aetna will mail the form and instructions to you. Submit the

completed form directly to Aetna.

Incomplete submissions may delay processing and result in retroactive deductions.

Step 2: Required documents

If a qualified life event occurs, you must provide documents that support your requested change. Learn more:

cfo.asu.edu/hr-benefitsfaqs.

If enrolling eligible dependents, you must provide d ocuments that demonstrate eligibility, including but not limited to: marriage certificate, birth

certificate or passport. Learn More: Page 3 of the Benefits Guide | Administration at cfo.asu.edu/hr-benefitsguide.

All required documents must be translated to English.

Important:

Do not delay in submitting this form if you are waiting to receive required supporting documentation.

Step 3: Submit your completed, signed form within 30 calendar days.

Submit the completed, signed form and required documentation by one of the following secure methods:

Fax

Confidential Benefits E-fax 480-993-0007

Hand deliver

HR Employee Service Center, Tempe University Center (UCNTRA), 1100 E. University Drive, Tempe

Mail

Arizona State University

Attn: Benefits

P.O. Box 871304

Tempe, AZ 85287-1304

Step 4: Verify your coverage.

Go to

Log into My ASU using your ASURITE ID and password.

Go to My Employment > Benefits > My Benefits Summary.

Change the effective date to your coverage effective date and click “Go.”

For coverage effective date information, visit cfo.asu.edu/hr-effectivedates.

For pay period start dates, view the payroll calendar at

cfo.asu.edu/hr-calendars.

HRESC@asu.edu.

Report all discrepancies immediately to the Office of Human Resources Employee Service Center at 855-278-5081 or

ID cards will be mailed to your home within 2-3 weeks after your enrollments are processed.

Additional information

 Learn more about plan features, premium rates, and Summary of Benefits and Coverage:

Benefits Guide|Health (cfo.asu.edu/hr-benefitsguide)

 If your covered dependents are employed by ASU, The University of Arizona, Northern Arizona University, the Arizona Board of Regents or the State of

Arizona, you and your dependents can only be covered on the same plans with one employer.



Plan provisions may require that you are actively at work on the effective date of coverage. Learn More:

Benefits Guide|Administration

Need Assistance? Office of Human Resources Employee Service Center | 855-ASU-5081 (855-278-5081) |

HRESC@asu.edu

Disclaimer:

The information contained in this form is provided to allow you to make benefit elections. If there are any discrepancies between this information and official documents, official

documents will govern. The State of Arizona, Arizona Board of Regents and Arizona State University reserve the right to modify any of its plans, in whole or part, at any time.

Fax pages 2-4 to 480-993-0007; keep page 1 for future reference.

Office of Human Resources | Benefits Design & Management

Page 1 of 4

Coverage effective on/after Jan. 1, 2016