Faculty and Staff Benefits

Forms

Forms are in Portable Document Format (PDF) and may be viewed using Acrobat Reader. You may complete the forms online and then print out a copy to sign and mail. You may also print out the form and complete them entirely by hand.

Initial Enrollment Form

• Benefit Enrollment Form (to be used for initial benefit enrollment, must be received within 30 days of eligibility)
• Beneficiary Designation Form (to be used for Basic Life, AD&D, and Pre-Retirement Death beneficiary designation)
• Group Life Evidence of Insurability (required for spouse life coverage above $20,000 and dependent life coverage above $5,000)
• Proof of Relationship Form
• Supplemental Life Insurance Enrollment and Change Form

Benefit Change Forms- To be used only for Family Status Changes or during Annual Enrollment

• Benefit Change Form (to be used to make a change to a current benefit enrollment)
• Flexible Spending Account Mid Year Change Form (to be used for applicable family status changes)
• Group Life Evidence of Insurability (to increase Basic Group Life to Option B or to increase Spouse and/or Child Life Insurance)
• Long Term Disability Evidence of Insurability (to increase Long Term Disability to option B)
• Proof of Relationship Form
• Supplemental Life Insurance Enrollment and Change Form

Claim Forms

• Dental Claim Form
• Express Scripts Prescription Drug Claim Form
• Express Scripts Prescription Mail In Form (8 ½" X 14" paper required for proper printing ­ please note both front & back side need to be printed)
• Flexible Spending Account Claim Form
• HIPAA Authorization for Release of Health Information Form (PDF 74 KB)
• Medical Claim Form (Coventry Health Care)
• Medical Claim Form (Great-West Healthcare)
• Medical Claim Form (United Health Care ­ for POS Choice Plus services prior to 1/1/08)
• VSP Out-of-Network Reimbursement Form

Retirement and Tax Deferred Annuity Forms

• Division of Benefits Order
• Faculty Performance Shares Option Exercise Request Notice A
• Faculty Performance Shares Option Exercise Request Notice B
• Notice of Intent to Retire Form
• Pre-tax 403b Salary Reduction/Disclosure Form
• Roth 403b Plan Salary Agreement/Disclosure Form
• Request for Review of Prior Service
• Request for Retirement or Vested Benefit Estimate Form
• Voluntary Salary Deferral Agreement Form (457b)