Benefits Enrollment and Change Worksheet

The Benefits Enrollment Worksheet allows a new or existing employees to enroll in or make changes to their insurance benefits plans.

Please review Enrollment Instructions below before proceeding.

Not for Open Enrollment Changes - Open Enrollment changes must be made through My CalPoly Portal
For more information about the plans offered or how to enroll, please visit the following pages or contact our benefits team at (805) 756-2236.

• https://afd.calpoly.edu/hr/benefits/health-insurance for health plans
• https://afd.calpoly.edu/hr/benefits/dental_vision_hearing or dental plans.

Enrollment Instructions

1. After launching the Benefits Enrollment Worksheet, an Adobe Sign Form will prompt you for your name and email address.
2. Before proceeding make sure you have the required information and documentation listed below; then complete all required fields.
3. The following information is needed to complete the worksheet:
   • Employee name, SSN, mailing address, phone number, marital status
   • Permitting event and permitting event date (i.e. new hire/hire date, adding new spouse/marriage date, adding newborn child/birthdate)
   • If adding dependent(s), legal name, SSN, birthdate, relationship and gender
   • Health and/or dental plan choices
4. The following documentation is required when adding dependents and can be attached directly to the Adobe Sign form:
   • Marriage Certificate or State of California Declaration of Domestic Partnership (County Issued Document)
   • Birth Certificate for Children (natural/step/adopted) (County Issued Document)
   • "Affidavit of Parent-Child Relationship” is required for child in a parent-child relationship who is NOT natural/step/adopted child