Benefits Administration - Publications and Forms

Publications and Forms

All files on this page are in Adobe Acrobat

format. As a convenience, the PDF forms allow you to fill in the requested information before printing. After filling in the necessary information you may print out the form, sign in the requested fields, and send the form to your agency benefits coordinator (typically located in the human resource section of your department). Do not send forms directly to Benefits Administration. All files listed below will open in a new browser window.

Please note: The data you fill out on these forms is NOT submitted electronically to your benefits coordinator. A printed form must be submitted to your agency to process any requested changes.

Forms

Enrollment/Change Application—State and Higher Education (FA-0820)
Enrollment/Change Application—Local Education (FA-0854)
Enrollment/Change Application—Local Government (FA-0978)
Basic Life Beneficiary Designation for Those Not Enrolled in Health (FA-1005)
Application for Special Enrollment by Qualifying Event (FA-0868)
Application for Late Enrollment — Medical Underwriting
Leave Without Pay—State and Higher Ed (FA-0867)
Leave Without Pay—Local Education and Local Government (FA-0953)
Application to Continue Insurance at Retirement non-TCRS* (FA-0857)
Application for Medicare Supplement non-TCRS* (FA-0983)
Request for Retroactive Transaction (FA-0938)
Optional Special Accident Enrollment Application (FA-0831)
Optional Term Life Enrollment Application (M-95201)
Optional Universal Life Enrollment Application (M-95090)
Optional Life Supplemental Application (M-95202)
Optional Life Customer Service Request Form (L-52490)