Non-Unit Dental Insurance Enrollment/Change form

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Benefited, Non-Unit employees may enroll for coverage in the Non-Unit Dental Insurance Plan:

• Within the first 21 calendar days of employment in a benefited, non-unit position. If hired on the first day of the month, coverages are effective on date of hire. If hired after the first day of the month, coverages are effective the first day of the following month.
• During October open enrollment any year for coverage effective the following January 1.
• Within 30 days, and with documentation, of a qualifying event such as involuntary loss of coverage under another plan.

This Non-Unit Dental Enrollment/Change form is completed by newly eligible employees and should be submitted to UMass Amherst Human Resources with supporting documentation* in order to request coverage. The completed form may be submitted in person at the Human Resources Employee Service Center or online via AskHR.

*Employees may elect individual or family Non-Unit dental insurance coverage. Supporting documents are required for a family plan, which may include coverage for the employee's spouse and/or dependent child(ren) up to 26 years of age. In order to provide coverage for a:

• Spouse, a copy of a marriage certificate is required.
• Dependent child(ren), birth or adoption documentation is required for each covered dependent.