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Total Rewards forms and guides

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Program
Topic
Document Type
 
Name/Description File type
Beneficiary designation form for active employees

Active employee Beneficiary Designation Form to be used for beneficiary designations for Basic Life, Supplemental Life, Accidental Death and Dismemberment, and pre-retirement death.

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Benefits Change Form for calendar year 2017

Use this form to change your insurance elections due to a family status change for the 2017 calendar year. This form cannot be used during the period of Annual Enrollment.

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Benefits Enrollment Form for calendar year 2017

Benefits Enrollment Form to be used for initial benefit enrollment by new employees or by employees newly eligible for insurance. Must be received within 31 days of eligibility. This form cannot be used during Annual Enrollment.

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Flexible spending account (FSA) enrollment change form for 2017

Flexible Spending Account (FSA) enrollment/change form for the 2017 calendar year.

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Health Savings Account (HSA) Enrollment/Change Form for calendar year 2017

This form is necessary for enrolling in a health savings account (HSA) for this first time, or to make a change to an existing HSA. It applies to calendar year 2017.

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Retiree beneficiary designation form

Form for retirees to designate beneficiaries for basic life, supplemental life, and accidental death and dismemberment plans. Cannot be used during retirees’ Annual Enrollment period.

Note: This retiree beneficiary designation form is available on pg. 3 of a combo pack of forms.

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Retiree Benefits Change Form and Retiree Beneficiary Designation Information (combo pack of forms)

Combo pack of forms, including: (1) Retiree benefits enrollment/change form to be used to change insurance elections. (2) Beneficiary designations form for basic life, supplemental life, and accidental death and dismemberment plans. Cannot be used during retirees’ Annual Enrollment period.

Note: The retiree beneficiary designation form is available on pg. 3.

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Supplemental Life- Enrollment and change form (Group Life Insurance Evidence of Insurability)

Use this form to enroll in the university’s supplemental life insurance plan, and also provide evidence of insurability, which is required for the plan.

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Evidence of insurability—Group Life, Spouse Life, Child Life

Form to confirm evidence of insurability for group life/dependent life insurance.

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Medical claim form for active employees (UHC)

Instructions on accessing the medical claim form for active employees under university medical insurance plans. UnitedHealthcare is the administrator.

Other
Proof of relationship requirement

Proof of relationship requirements to confirm the individual or individuals to be covered are eligible under the specific definitions of the plans.

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Statement of Health Form - Evidence of Insurability - Long Term Disability

Form from MetLife to increase Long Term Disability insurance to Option B.

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University of Missouri Affirmation of Sponsored Adult Dependent Partnership

Form for establishing a sponsored adult dependent relationship for the purpose of university benefits

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Dental claim form

Claim form for the university Dental Plan.

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Flexible spending account (FSA) claim form

Claim form for flexible spending accounts (FSA).

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Medical claim form for retirees (Coventry) for 2016

Medical claim form for retirees under university medical insurance plans for calendar year 2016. Coventry is the administrator.

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Medicare Part D prescription drug claims form

Express Scripts Medicare Part D prescription claims form.

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Prescription drug claims form

Express Scripts prescription claims form.

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Prescription drug mail-in form

Express Scripts prescription drug mail-in order form.

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VSP Out-Of-Network Reimbursement Form

Form for reimbursing expenses incurred at out-of-network providers

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Beneficiary Designation form - Supplemental life insurance

Designate beneficiaries for the university’s supplemental life insurance plan.

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Health Savings Account (HSA) Closure Form

This form is for individuals who are currently enrolled in an HSA through the Healthy Savings Plan, a qualified high-deductible plan. Completion of this form will cancel your enrollment.

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University of Missouri Affidavit of Termination of Sponsored Adult Dependent Partnership

Use this form to terminate a sponsored adult dependent relationship for university benefits

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Release of health information form (HIPAA)

Form for authorization of release of personal health information under HIPAA.

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Tuition Reduction Form for Spouse and Dependents (UM 85)

Form to request tuition reduction for a spouse or dependent of an eligible university employee. Locate Form 85 on the Human Resources Forms webpage.

If you are seeking tuition assistance for a spouse/dependent for the first time, please be aware that proof of relationship will be required. On the forms and guides list for educational/tuition assistance, you may access the proof of relationship requirements for children, spouses, and Sponsored Adult Dependents, as well as the Sponsored Adult Dependent form should you need it.

Also you may visit the tuition assistance webpage for an overview of the program. Or contact your Campus Benefits Representative or the HR Service Center to find out if proof of relationship is already on file with the Office of Human Resources.

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University of Missouri Educational Assistance Form for Employees (UM 84-1)

Form for eligible employees to receive university tuition assistance. Locate Form 84-1 on the Human Resource Forms webpage.

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Patient Health Questionnaire-9 (PHQ-9) Depression Self Assessment Form

Questionnaire to help you begin to explore whether the feelings, thoughts, or behaviors you may be experiencing could be depression

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Midyear Tobacco Attestation


Employees who attested to being tobacco free during the last Annual Enrollment do not need to complete this midyear attestation. This attestation is available for employees who (1) attested to being in a tobacco cessation program, (2) attested to being a tobacco user, or (3) defaulted during the last Annual Enrollment.
 

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Long term disability waive coverage form

Use this form to waive long term disability coverage.

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