Enrollment Forms

2018 Benefits Annual Enrollment


Use these forms for changes effective during calendar year 2018. For changes effective during calendar year 2017, use the 2017 forms.

Forms should be submitted to the Benefits section of Human Resource Management at:

433 Bolivar St. Suite 626 New Orleans LA 70112

Fax: 504.568.2212


Enrollment Forms:

Health and Prudential Life (GB-01)

Dental, Vision & Identity Theft Protection

Financial Protection (United Healthcare Life, Critical Illness Protection, Accident Protection, Long Term Disability, Accidental Death & Dismemberment)

Flexible Spending Accounts

Health Savings Account

Long Term Care


Evidence of Insurability Forms:

Prudential Life

United Healthcare Life and Long Term Disability

Long Term Care