Looking for Open Enrollment Forms?

Click here to be redirected to the Statewide Open Enrollment page.  All of the forms you need for Open Enrollment can be found there. 

The forms listed below are for those employees who need to make changes effective prior to 7/1/2016.


Changing Benefit Options

Changes to employee selected optional benefits can only be made when the employee experiences a Major Life Event or during Annual Benefits Open Enrollment

Open Enrollment typically runs from mid-April through mid-May.  Filing your tax return?  Start thinking about what changes you'll want to make to your insurance.  Any changes you make during Open Enrollment will go into effect on July 1st. 

Major Life Event

Do you think you may have experienced a major life event?  The following are examples of major life events:

  • Marriage, divorce or legal separation
  • Death of the employee's spouse or dependent
  • Birth or adoption of a child by the employee
  • Change in employment status of the employee's spouse (i.e. new job, retired)
  • Change in the employee's employment status (i.e. part-time to full-time, significant schedule change)
  • Going on an unpaid leave of absence
  • Significant change in the insurance coverage provided by the employee's spouse
  • Gaining or involuntarily losing health care coverage for a dependent

If you have a major life event, you'll have the opportunity to make changes to your insurance coverage.  The list below is intended to help you understand what types of changes you are able to make and what forms you need to submit changes.  Please be advised that any changes that alter your insurance coverage must be received by Human Resource Services within 30 days of the major life event.  The only exception is when adding a newborn; you have 60 days to submit that paperwork.

If you are adding or re-enrolling dependents, don't forget that we will need proof of dependent eligibility.  Eligible documents include:  birth certificate, adoption papers, marriage certificate, divorce decree, or the first page of last year's tax return. 

UA Choice Health Plan Enrollment Form

Use this form to enroll in or drop coverage for the 750, HDHP, and CDHP Plans.  If you are adding dependents, you'll need to submit this form along with the UA Choice Health Plan Dependent Enrollment Form (see below).

UA Choice Dependent Enrollment Form

Use this form to add/drop dependents on the 750, HDHP, and CDHP Plans.  If you are currently set up as Employee Only and need to add dependents, you'll also need to submit the UA Choice Health Plan Enrollment Form (see above).

Health Savings Account

This form should be used to begin, end, or change enrollment in the Health Savings Account (HSA).  The HSA option is only available to employees who have enrolled in the CDHP Plan.  Extended Temporary employees cannot enroll in the HSA.

Opt Out Form

Don't need the UA insurance anymore?  If you have credible coverage through another source, you can opt-out of the UA Choice Plan.  Please be sure to provide us with information on your other insurance. 

UA Choice Supplemental Benefits Election Form

Use this form to start, stop or change your Flexible Spending Account (FSA) deductions, Life Insurance and Accidental Death & Dismemberment Insurance.  The Health Care FSA is only available to those employees who are enrolled in the 750 or HDHP Plan. Extended Temporary employees cannot enroll in supplemental benefits.

Looking to change your Health Savings Account?  Use the Health Savings Account Enrollment Form.

Evidence of Insurability Enrollment Form

If you are electing life insurance over $200,000, you will need to complete the Evidence of Insurability Form.  Please mail this form directly to Standard Insurance (their address is on the top of the form).  Do not submit the form to HRS.  You'll be enrolled with life insurance at the $200,000 level until the HRS department is notified that you were approved at a higher level.

Beneficiary Form

Use this form to update your beneficiaries for the Standard Life Insurance, Accidental Death & Dismemberment Insurance and the Supplemental Life Insurance policies.  You can submit an updated beneficiary form at anytime.  Please note that beneficiary information is not maintained electronically.  If you have doubts about who you listed, please submit a new form. 

Do you want to change your beneficiaries for your retirement plans?  You'll need to work with the various vendors or the State of Alaska Division of Retirement.  UAA does not maintain beneficiary information for the retirement plans.

  • State of Alaska Division of Retirement & Benefits:   1-800-821-2251
  • Fidelity:    1-800-343-0860
  • Valic:   1-800-448-2542
  • TIAA-CREF:   1-800-842-2776
  • Lincoln Financial:   1-800-454-6265

Statement of Financial Interdependence

This form is required to document a Financially Interdependent Partner (FIP).  If you are adding a FIP to your insurance, this will serve as the proof of dependent eligibility.  If you want to learn more about what constitutes a FIP and to see if you qualify, please read the Financial Interdependent Relationship Explanation.

W4 Form

Use this form to make changes to your federal tax withholdings. 

UA Change Form

Use this form to make changes to your address, name or marital status.  Be sure to mark the box next to Employee Related Address - HR.  This will update your information with Premera, PERS/TRS, VSP and your ORP Retirement Vendor.  Please note that if you change your address in UA Online, it does not update information with the vendors listed. 

Still have questions?  Please call us at 907.786.4608.