HUMAN RESOURCES MANAGEMENT
BENEFITS DROP/ADD FORM
I, SS#
DO HEREBY AUTHORIZE ALBANY STATE UNIVERSITY TO DROP/ADD THE FOLLOWING BENEFITS:
INDIVIDUAL HEALTH INSURANCE COVERAGE DROP ADD
FAMILY HEALTH INSURANCE COVERAGE DROP ADD
INDIVIDUAL DENTAL INSURANCE COVERAGE DROP ADD
SUPPLEMENTAL LIFE (1), (2), (3) DROP ADD
FAMILY LIFE COVERAGE DROP ADD
SECTION 125 (FOR SUPPLEMENTAL LIFE) DROP ADD
FLEXIBLE SPENDING ACCOUNT-MEDICAL DROP ADD
FLEXIBLE SPENDING ACCOUNT-DEPENDENT CARE DROP ADD
RETIREE WITH MEDICARE DROP ADD
RETIREE WITH DEPENDENTS WITH MEDICARE DROP ADD
REASONS FOR CHANGES MADE
RETIREMENT TERMINATION VOLUNTARY OPEN ENROLLMENT
ADDITIONS OR DELETIONS OF COVERAGE MAY ONLY BE MADE DURING OPEN ENROLLMENT OR WITHIN 31 DAYS
OF APPROVED CHANGE OF STATUS DUE TO :
A. ACQUIRING DEPENDENTS
B. LOSS OF DEPENDENTS BY:
1. DEATH
2. DIVORCE
3. MARRIAGE
4. MARRIAGE OF A DEPENDENT
5. ATTAINMENT OF MAXIMUM AGE COVERED
6. SPOUSE LOSS OF COVERAGE UNDER THIS PLAN BECAUSE OF CHANGE OF EMPLOYMENT
STATUS
I HAVE BEEN ADVISED OF MY RIGHTS TO CONTINUE MY HEALTH/DENTAL INSURANCE COVERAGE UNDER COBRA.
1, DO DO NOT, WISH TO CONTINUE MY HEALTH INSURANCE UNDER COBRA.
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SIGNATURE DATE
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WITNESS DATE
