Benefits Election

Benefits Election

This form is required to enroll or waive Health, Dental, Vision, and Optional Coverage Benefits. 

Download the form and complete electronically. 

Note: When you first click on the link to download the form, you will be in document preview mode, and cannot enter data into the form. Click the download icon  in your browser in order to edit, save, or print the form in Adobe Acrobat.

If you are unable to access the form or receive an error message, send a screenshot of your entire screen and the message to hrbenefits@austincc.edu. Assistance will provided as soon as possible.

Bring your completed form to new employee orientation (NEO) and provide it to the Benefits Administrator. If you do not have access to a printer, a blank form will be available at NEO. 

Use this form to enroll eligible dependents, Social Security Numbers are required.