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Forms to Process Changes

*** Only complete the forms that pertain to your current benefit coverage ***

Benefit forms need to be completed when a benefit eligible staff or faculty member changes address, marital status, and/or benefit plan enrollment. These forms need to be completed and returned to the Human Resources office within 30 days of the qualifying event and/or status change.

  • Qualifying EventsA change in your situation — like getting married, having a baby, or losing health coverage — that can allow benefit plan changes outside the yearly Open Enrollment Period
  • Verifying dependents: When enrolling a spouse or child (or changing a spouse or child’s enrollment) in University Benefits, documentation demonstrating the current spousal or child relationship may be required

Required Form for all changes:

Optional Forms, dependent upon the change:

Additional Contribution to Retirement Plan Forms

If you are currently enrolled in the voluntary 403(b) contribution plan, you may change your contribution amount by completing the form for your provider.

If you are not currently enrolled in the voluntary 403(b) contribution plan, please contact the Office of Human Resources at (570) 941-7767.

Please submit the completed Salary Reduction Agreement to the Office of Human Resources.  If you would like to maximize your contribution or you have questions, please contact BethAnn McCartney, Benefits Manager, at (570) 941-7767