Enrollment Forms

2020 Benefits Annual Enrollment


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

  • Hand-delivery:  433 Bolivar St., Suite 626, New Orleans, LA 70112 (campus mail not recommended)
  • Fax: (504) 568-2212; Attn: Benefits
  • Email:  nohrmbenefits@lsuhsc.edu  (To ensure security, use your lsuhsc.edu email address to send benefits documents.)


Enrollment Forms:

Health and Prudential Life (GB-01)

Health Savings Account - Enrollment & Payroll Deduction Election (must be completed each year for those enrolled in Pelican HSA775, Form GB-79)

LSU First Prescriber Monitoring Attestation (must be completed once for employees enrolled in LSU First Health Plan and are practitioners with prescribing authority)

Dental, Vision & Identity Theft Protection

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

Flexible Spending Accounts 

Long Term Care


Evidence of Insurability Forms (Required if enrolling more than 30 days after your date of hire) :

Prudential Life 

United Healthcare Life and Long Term Disability 

Long Term Care