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2018 Benefits Program Qualifying Event Change Form

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Employee ID__________ (Required) 1 2018 Benefits Program Qualifying Event Change form Please Print - Please Complete ALL Applicable Sections If you have any questions, please contact the University of Rochester Office of Total Rewards at (585) 275-2084 or (585) 272-0227 Please return completed forms to: Office of Total Rewards, 60 Corporate Woods, Suite 310, Box 270453, Rochester, NY 14627; Fax: 585-272-0227 or Email: Employee Information Name (Last, First, Initial) Please Print: ________________________________________ ____________________________________ Address: ________________________________________ ________________________________________ ____________________ _____________________

Employee ID_____ (Required) 1 . 2018 Benefits Program Qualifying Event Change Form . Please Print - Please Complete ALL Applicable Sections . If you have any questions, please contact the University of Rochester Office of Total Rewards at (585) 275-

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