Submit the completed form to your benefits coordinator or the HHS Employee Service Center if you are an HHS Enterprise employee. Forms can be submitted via email, fax, or mail. For email submissions, send to benefits@ers.state.tx.us. Fax submissions can be sent to (512) 867-7438. For mail submissions, send to: Employees Retirement System of Texas, PO Box 13207, Austin, Texas 78711-3207. It is important to keep a copy of the submitted form for your records. Ensure that you adhere to any deadlines related to your benefits enrollment or changes.

Important dates for this form in 2024 and 2025 include: January 1, 2024 - Start of the new benefits year. March 31, 2024 - Deadline for making changes to benefits due to qualifying life events that occurred in the previous quarter. July 1, 2025 - Enrollment period begins for the next benefits year. September 30, 2025 - Deadline for submitting proof of dependent eligibility for newly added dependents during the open enrollment period.

The purpose of this form is to facilitate the election and management of employee benefits for members of the Texas Employees Retirement System. Employees use this form to select their desired health, dental, life insurance, and other optional coverage options. Additionally, this form serves as a means for employees to update their personal information, certify their tobacco use status, and add or remove dependents from their coverage. By completing this form, employees can ensure that their benefits are accurately administered. Employees are required to fill out this form whenever there is a change in their employment status, personal information, or benefits needs. This form must be submitted to the appropriate benefits coordinator or service center to ensure timely processing and avoid any disruption in coverage.

• 1. Employee Data: Includes fields for Social Security Number, Employee ID, Name, contact information, and employment details.
• 2. Action: Specifies the type of action being requested, such as new hire, rehire, leave of absence, etc.
• 3. Reason Code: Includes a list of reason codes for making changes during the plan year.
• 4. Benefits Options: Allows employees to elect, waive, or change various health and optional benefits.
• 5. Dependent Personal Data: Collects information about dependents, including their name, date of birth, social security number, and tobacco use certification.
• 6. Authorization: Requires the employee's signature to authorize payroll deductions and certify the information provided on the form.
• 7. Family Status Change Reference Chart: Provides a reference for qualifying life events and corresponding reason codes when making changes to benefits.

Failure to submit this form in a timely manner may result in delays or loss of benefits coverage.

• Loss of Coverage: Employees may lose their health, dental, or other benefits coverage if the form is not submitted.
• Inaccurate Records: The Employees Retirement System of Texas may have incorrect information on file, leading to administrative issues.
• Missed Deadlines: Missing important submission deadlines can affect eligibility for certain benefits or coverage options.

• 1. New Hire: Use this form to elect initial benefits coverage when you are newly hired.
• 2. Life Event: Submit the form within 31 days of a qualifying life event, such as marriage, birth, or adoption.
• 3. Transfer: Complete this form if you are transferring from another participating agency without a break in coverage.
• 4. Dependent Changes: Use this form to add or remove dependents from your benefits coverage.
• 5. Tobacco Certification: Certify or update your tobacco use status as required by the Employees Retirement System of Texas.