Reimbursement Account Enrollment Form
For Employees Experiencing a Qualifying Life Event
If you are experiencing a qualifying life event, such as marriage, divorce, birth, or adoption, please complete the enrollment form below to enroll or make
changes to the health care and/or dependent care reimbursement accounts. A completed enrollment form along with supporting documentation must be received
within thirty (30) days of the event by Duke Benefits at 705 Broad Street (Box 90502), Durham, NC 27705 (fax number 919-681-8774).
For Newly Hired Employees
If you are a newly hired employee, please complete the enrollment form below to participate in the health care and/or dependent care reimbursement accounts. A completed
enrollment form must be received within sixty (60) days of your date of hire by Duke Benefits at 705 Broad Street (Box 90502), Durham, NC 27705 (fax number 919-681-8774).
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* Some Duke HR forms may require you to list your Duke Unique ID. If you do
not know or are unsure of your Duke Unique ID, you can look it up
here.
** Some forms available on this web site are in Adobe Portable Document Format (PDF). You will need
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to view and print these forms.
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