University of Missouri System

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-Optional Life Insurance Enrollment Form (to enroll in Supplemental Life Insurance, must also complete Evidence of Insurability)
• Supplemental-Optional Life Insurance Evidence of Insurability

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-Optional Life Insurance Beneficiary Designation and Change (use this form for a new beneficiary designation or to change a designation for Supplemental-Optional Life Insurance)
• Supplemental-Optional Life Insurance Evidence of Insurability

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)