Benefits Forms
Medical/Dental Enrollment Forms & Information
Use these forms to select or opt out of your plan for yourself and your dependents.
- 2026 Medical/Dental Group Enrollment Form (PDF)
- Affidavit of Working Spouse/Domestic Partner Insurance Status (PDF)
- Opt-Out Affidavit (PDF)
- COBRA Acknowledgement Form (PDF)
- Dependent Verification Form (PDF) - must be submitted along with supporting documentation
Plan Booklets, Plan Summaries, and Premium Charts
Get a full understanding of plan costs and details using the resources below.
- 2026 Medical Comparison Chart - Non-Represented Staff (PDF)
- 2026 Medical Comparison Chart - AFSCME (PDF)
- 2026 Medical Comparison Chart - KSUFA (PDF)
- 2026 Contribution Table (PDF)
- 2026 COBRA Rates (PDF)
Provider Contact Information
New Hire Information
Benefit Notifications
- Employee Privacy Notice (PDF)
- Change of Personal Information (PDF) (Add/Delete Dependents)
Dental (Delta Dental)
- Dental Orthodontic Services Information
- Dental LOW Coverage Summary (PDF)
- Dental BASIC Coverage Summary (PDF)
- Dental HIGH Coverage Summary (PDF)
- KSUFA High Plan (PDF)
Domestic Partner
- Domestic Partner Guidelines (PDF)
- Domestic Partner Important Tax Information (PDF)
- Domestic Partner Affidavit (PDF)
- Domestic Partner Termination Affidavit (PDF)
Employee Assistance Program
Health Savings Account (HSA) and Flexible Spending Accounts (PNC Bank)
- PNC Bank FSA Reimbursement Form (PDF)
- 2026 HSA Enrollment Form (PDF)
- 2026 HSA Change Form (PDF)
- 2026 FSA Enrollment Form (PDF)
- PNC Direct Transfer Form for HSAs (PDF)
Life Insurance, AD&D, and Long-Term Disability
Stay tuned for updated files and forms.
Medical Plan Forms
Prescription (CVS/Caremark)
Retirement Plans
- Supplemental Vendor Contact List
- Retirement Plan Election Form OPERS/STRS (PDF) (Full-Time Faculty, Unclassified, & Classified Staff)
Tuition
- Proof of Dependency Status for Tuition Waiver Form (PDF)
- Tuition Waiver Request for ROTC Staff, Retirees & Disabled EMPLOYEES (PDF)
- Tuition Waiver Request for DEPENDENTS of ROTC Staff, Retirees & Disabled Employees (PDF)
- Tuition Waiver Request for VSIP (Voluntary Separation) Employees and Dependents (PDF)
Vision (EyeMed)
Voluntary Supplemental Insurances
Stay tuned for updated files and forms.
Workers' Compensation
- Bureau of Workers' Compensation First Report of Injury
- Employee Report of Injury or Occupational Illness (PDF)
