Benefits Forms

Go to the 2015 Annual Enrollment webpage

This page is for actively employed faculty and staff. Retirees should obtain forms from the Retiree Forms webpage. 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 Forms

2015 2014
2015 Benefit Enrollment Form - to be used for initial benefit enrollment; must be received within 31 days of eligibility 2014 Benefit Enrollment Form - to be used for initial benefit enrollment; must be received within 30 days of eligibility
2015 Flexible Savings Account (FSA) Enrollment Form N/A
2015 Health Savings Account Enrollment/Change Form  - to be completed if enrolling in the Healthy Savings Plan and qualified for an HSA 2014 Health Savings Account Enrollment Form - to be completed if enrolling in the myOptions Plan and qualified for an HSA
Health Equity Custodial Agreement Same as 2015
Beneficiary Designation Form - to be used for Basic Life, AD&D, and Pre-Retirement Death beneficiary designation Same as 2015
Group Life Evidence of Insurability - required for Spouse or Sponsored Adult Dependent Life Insurance above $20,000, and for Child Life Insurance above $5,000 Same as 2015
Proof of Relationship Form Same as 2015
Affirmation of Sponsored Adult Dependent Partnership Same as 2015
Supplemental Life Insurance Enrollment and Change Form Same as 2015

 

Benefit Change Forms

To be used only for Family Status Changes or during Annual Enrollment

2015 2014
2015 Benefit Change Form - to be used to make a change to a current benefit enrollment, outside of the annual enrollment period, due to a change in family status 2014 Benefit Change Form - to be used to make a change to a current benefit enrollment
Termination of Sponsored Adult Dependent Partnership Same as 2015
2015 Health Savings Account Enrollment/Change Form - to be completed if enrolling in the Healthy Savings Plan and qualified for an HSA 2014 Health Savings Account Enrollment Form - to be completed if enrolling in the Healthy Savings Plan and qualified for an HSA)
2015 Health Savings Account Closure Form 2014 Health Savings Account Closure Form
FSA Mid-Year Change Form Same as 2015
Group Life Evidence of Insurability - required to (1) increase Basic Group Life to Option B or (2) increase Spouse, Sponsored Adult Dependent, and/or Child Life Insurance Same as 2015
Long Term Disability Evidence of Insurability - to increase Long Term Disability to option B Same as 2015
Proof of Relationship Form Same as 2015
Supplemental Life Insurance Enrollment and Change Form Same as 2015
Supplemental Life Insurance Cancellation Form Same as 2015
Supplemental Life Insurance Beneficiary Designation Form Same as 2015

 

Claim Forms

 

Retirement Plan and Voluntary Retirement Plan Forms

Reviewed 2014-11-03.