Benefit 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)
- Health Savings Account Enrollment/Change Form
- FSA Mid-Year Change Form
- 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
- Supplemental Life Insurance Cancellation Form
- Supplemental Life Insurance Beneficiary Designation Form
Claim Forms
- Wellness Screening Form
- Delta 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)
- MHNet Claim Form
- VSP Out-of-Network Reimbursement Form
Retirement and Voluntary Retirement Plan Forms
- Division of Benefits Order
- Faculty Performance Shares Option Exercise Request
- Notice of Intent to Retire Form
- Request for Review of Prior Service
- Request for Retirement or Vested Benefit Estimate Form
Reviewed 2013-04-17.
