Quick Links
Dental Benefits
- Eligibility
- Enrollment
- Dental Plans
- Dental Carriers
- State-Sponsored Dental Plan Premium Information (Employee Cost)
- Union-Sponsored Dental Plan Information (Bargaining Units 5 and 6)
- 2009 Dental and Vision Plan Premiums (13 KB PDF)
- Employee Cost Comparison
- COBRA Continuation Coverage
Publications
Forms
- Dental Plan Enrollment Authorization - STD 692 (PDF)
- Dental Plan Direct Payment Authorization - STD 696 (PDF)
- Affidavit for Economic Dependent Children - DPA 025 (Word Document)
- Affidavit for Domestic Partners Being Claimed as Economic Dependents - DPA 680 (Word Document)
- Affidavit for Employees - Gender Verification of Married Persons and Notice of Imputed Tax - DPA 880 (PDF) - Note: Based on recent changes in State law, the DPA 880 can be used only for marriages that occurred before November 5, 2008
- Retiree Dental Enrollment/Change Request (PDF)
COBRA Forms
- COBRA Initial General Notice (Word Document)
- COBRA Initial General Notice Log (Word Document)
- COBRA Election Notice (Word Document)
- COBRA Election Notice Log (Word Document)
- COBRA Election Form (PDF)
- COBRA Notice of Unavailability of Continuation Coverage (Word Document)
- COBRA Monthly Status Report (Word Document)
- COBRA Calendar (PDF)
- COBRA Premium Assistance and Election Notice - American Reinvestment and Recovery Act of 2009 (PDF)
For More Information
Please contact your personnel office if you have any questions.
Updated March 18, 2009 at 4:31 PM.