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Total Rewards forms and guides

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Audience
Program
Topic
Document Type
 
Name/Description File type
Benefits Guide for the 2017 calendar year

A brief overview of the many benefits that comprise faculty and staff members’ total rewards package.

PDF
2017 benefits premiums

The 2017 benefits premiums are found within the 2017 Total Rewards guide.

PDF
2017 comparsion charts

The 2017 medical plan comparison chart can be found as part of the 2017 Total Rewards guide.

PDF
Custom Network Plan slicksheet

One-page summary of the Custom Network Plan offered by University of Missouri System.

PDF
Dental slicksheet

One-page summary overview of the university Dental Plan.

PDF
Flexible Spending Account slicksheet

One-page summary of the Flexible Spending Accounts offered by the University of Missouri System.

PDF
Health Savings Account slicksheet

One-page summary of the Health Savings Account offered by the University of Missouri System

PDF
Healthy Savings Plan slicksheet

One-page summary of the Healthy Savings Plan offered by UM System.

PDF
PPO Plan slicksheet

One-page summary of the PPO Plan offered by the University of Missouri System.

PDF
Vision slicksheet

One-page summary overview of the university Vision Plan.

PDF
FAQs: University-sponsored Medicare Advantage plans

Frequently asked questions about university-sponsored, group Medicare Advantage plans offered through UnitedHealthcare effective January 1, 2017.

PDF
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.

PDF
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.

PDF
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.

PDF
Flexible spending account (FSA) enrollment change form for 2017

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

PDF
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.

PDF
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.

PDF
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.

PDF
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.

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

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

PDF
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.

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

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

PDF
University of Missouri Affirmation of Sponsored Adult Dependent Partnership

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

PDF
Dental claim form

Claim form for the university Dental Plan.

PDF
Flexible spending account (FSA) claim form

Claim form for flexible spending accounts (FSA).

PDF
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.

PDF
Medicare Part D prescription drug claims form

Express Scripts Medicare Part D prescription claims form.

PDF
Mental health member claim form and submission guidelines (Coventry)

Mental health member claim submission guidelines and claim form for MHNet Behavioral Health

PDF
Prescription drug claims form

Express Scripts prescription claims form.

PDF
Prescription drug mail-in form

Express Scripts prescription drug mail-in order form.

PDF
VSP Out-Of-Network Reimbursement Form

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

PDF
Beneficiary Designation form - Supplemental life insurance

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

PDF
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.

PDF
Optional Term Life Insurance Change Request (supplemental life)

Use this form to cancel your supplemental life insurance plan

PDF
University of Missouri Affidavit of Termination of Sponsored Adult Dependent Partnership

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

PDF
Release of health information form (HIPAA)

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

PDF
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.

PDF
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.

PDF
University of Missouri Educational Assistance Form for Retired Employees (UM 177)

Form (as Excel spreadsheet) for eligible retirees to receive university tuition assistance. Locate Form 177 on the Human Resource Forms webpage.

Excel
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

PDF
Accidental Death and Dismemberment Summary Plan Description (SPD) for calendar year 2016

Summary plan description for the University of Missouri System Accidental Death and Dismemberment insurance plan for 2016.

PDF
Accidental Death and Dismemberment Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the University of Missouri System Accidental Death and Dismemberment insurance plan for 2017.

PDF
Custom Network Summary Plan Description (SPD) for calendar year 2016

Summary plan description for the university Custom Network Plan for 2016.

PDF
Custom Network Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the university Custom Network Plan for 2017.

PDF
Dental Summary Plan Description (SPD) for calendar year 2016

Summary plan description of the Dental Plan for 2016.

PDF
Dental Summary Plan Description (SPD) for calendar year 2017

Summary plan description of the Dental Plan for 2017.

PDF
Dependent Life Insurance Summary Plan Description (SPD) for calendar year 2016

Summary plan description of the Dependent Life Insurance plan for 2016.

PDF
Dependent Life Insurance Summary Plan Description (SPD) for calendar year 2017

Summary plan description of the Dependent Life Insurance plan for 2017.

PDF
Flexible Benefit Summary Plan Description (SPD) for calendar year 2016

Summary plan description of the Flexible Benefit plan for 2016.

PDF