IMPORTANT: If enrolling any dependents on your Health/Dental plan, documents proving dependent eligibility MUST be submitted WITH YOUR APPLICATION.  Addition of spouses require copy of marriage certificate. Addition of children require copy of the birth certificate(s).  Addition of children between the ages of 19-26 to the dental plan also require a completed student dependent certification form.  Applications sent without dependent documentation will not be processed.

Forms MUST BE RECEIVED no later than November 19, 2021 and should be submitted either:

  1. Via email to: using “Open Enrollment” or “OE” in the subject line
  2. To your department Payroll Clerk
  3. To the Employee Benefits office via interoffice or US mail to: Employee Benefits, 421 Montgomery St. 15th Floor, Syracuse NY 13202

Questions can be submitted by email to or you may call the benefit office at 315-435-3498.

Please note that any enrollment/change forms for Deferred Comp or Short Term Disability should be sent directly to the vendor.  Employee Benefits does NOT manage those programs and cannot accept forms for those programs. Please refer to our “Other Benefits” page for more information.

Health/Dental Insurance Enrollment/Change Form 

Flexible Spending Enrollment Form

Student Dependent Certification Form (for dental coverage for children ages 19-26) 

For an LTD Enrollment Form please contact Employee Benefits to request a quote on your coverage choices by emailing using the words “LTD Quote” in the subject line or calling the Employee Benefits office.

Health / Dental Rates: 2022 Rates without MVP

Annual Open Enrollment Letter 2021 for a copy of the Open Enrollment notice mailed to your home mailing address