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Total Rewards forms and guides

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Audience
Program
Topic
Document Type
 
Name/Description File type
University of Missouri Deferred Vested Benefits - Designation of Beneficiary for Death Benefit

Designate beneficiaries for the Retirement, Disability and Death (RDD) Benefit Plan’s Deferred Vested Benefit.

PDF
University of Missouri Deferred Vested Benefits - Designation of Beneficiary for Guaranteed Period

Designate beneficiaries for the Retirement, Disability and Death (RDD) Benefit Plan’s Guaranteed Period Option.

PDF
University of Missouri Retirement Benefits - Designation of Beneficiary for Guaranteed Period

Designate beneficiaries for retirement benefits under the Retirement, Disability and Death (RDD) Benefit Plan’s Guaranteed Period Option.

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
Employee’s Illinois Withholding Allowance Certificate and Instructions (IL W-4)

You must complete this form so your employer can withhold the correct amount of Illinois Income Tax from your pay.

NOTE: You will be redirected to the Illinois Revenue website to access this form.

PDF
Faculty Performance Shares Plan Option Exercise Request Notice

Form used to exercise the option to sell shares of Fidelity Investments Asset Manager 50%, to which an individual may be entitled under the terms and conditions of the University of Missouri Faculty Performance Shares Plan.

PDF
Missouri Department of Revenue Withholding Certificate for Pension or Annuity Statements (MO W-4P)

This certificate is for voluntary withholding of Missouri State Income Tax from pension or annuity income only.

NOTE: You will be redirected to the Missouri Department of Revenue website to access this form.

PDF
Release of health information form (HIPAA)

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

PDF
Statement of Tax Responsibility form

Form for formally requesting the university to not withhold Missouri income taxes from pay due to an employee performing services for the university outside of Missouri, or an employe being a retiree residing outside of Missouri.

PDF
Witholding Certificate for Pension or Annuity Payments (IRS Form W-4P)

Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s).

NOTE: You will be redirected to the IRS website to access this form.

PDF
Request for Retirement or Vested Benefit Estimate

Use this form to request an estimate of your retirement or vested benefit estimate

PDF
Request for Review of Prior Service

Complete and submit this form in order for the University of Missouri System Retirement Program to review your prior service with the university. To be eligible for any prior service, your previous employment must have been at least one year in length with an FTE of at least 75%.

PDF
University of Missouri Retirement, Disability and Death Benefit Plan Division of Benefits Order

​Division of benefits order template to specify division of university pension benefits upon divorce.

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
Flex place arrangement form

This is an optional form that may be used at the manager’s discretion for setting up a flex place arrangement for an employee.

Word
Flexible work arrangement form

This is an optional form that may be used at the manager’s discretion for setting up a flexible work arrangement for an employee.

Word
Healthy for Life access and confidentiality agreement

Healthy for Life faculty or staff members, consultants, volunteers or students at the University of Missouri System may learn of, or have access to, confidential information. This agreement clarifies what confidential information is and what the corresponding responsibilities are.

PDF
Healthy for Life consent to participate and waiver of liability

Participants in the Healthy for Life weight-loss and physical activity classes must sign this consent to participate and waiver of liability form.

PDF
Million Step Pedometer Program pedometer tracker

Those participating in the Million Step Pedometer Program can use this handy spreadsheet to keep track of your steps, and has formulas to easily offer up your averages and totals.

Excel
Million Step Pedometer Program step submission and rebate form

Submit your steps by uploading a screenshot as proof of each million steps you take. Instructions and tips for uploading a screenshot are provided on the form. You must submit each one-million-step accomplishment within one year of completion in order to claim prizes. Multiple prizes may be distributed to a participant who claims more than one milestone achievement at one time at the discretion of Healthy for Life. Request a rebate by uploading a copy of your receipt from a rebate-eligible retailer. While participants may use any step-tracking device, only a Fitbit purchased at a University of Missouri Campus Store or UM Health System pharmacy is eligible for a rebate. 

Other
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
Request a wellness presentation

If your office would like to learn more about a wellness topic, use our form to request a presentation.

Other
Ride to Wellness miles submission and rebate form

Submit your miles by uploading a screenshot as proof of each 500 miles you have ridden. Instructions and tips for uploading a screenshot are provided on the form. Claim a prize from our current prize list. You must submit each 500 mile accomplishment within one year of completion in order to claim prizes. Multiple prizes may be distributed to a participant who claims more than one milestone achievement at one time at the discretion of Healthy for Life. Request a rebate by uploading a copy of your receipt from a rebate-eligible retailer. While participants may use any odometer, only the Cateye Velo9 purchased at a university bookstore is eligible for a rebate

Other
Ride to Wellness Odometer Tracker

Keep track of your Ride to Wellness odometer readings over time with this handy Microsoft Excel spreadsheet that includes formulas to calculate your averages and totals throughout each week.

Excel
Share your wellness success story

We've heard some great stories from you. Keep them coming by sharing your own success story via our online form.

Other
Wellness Ambassador sign up

Wellness Ambassadors help to promote a culture of health among faculty and staff. Anyone can be a Wellness Ambassador. By joining the team, you can help others be more active, relieve stress, eat healthier and much more.

Other
Job audit questionnaire (JAQ)

Another job evaluation tool that is designed to collect detailed information about the duties and responsibilities of the job as it currently exists from the job incumbent’s point of view. The collected job data will be used to help develop or revise job descriptions and evaluate the job for appropriate classification.

PDF
Position classification questionnaire- Information Technology (IT) addendum

For use with the full Position Classification Questionnaire (PCQ) when job is in the IT job family.

PDF
Position classification questionnaire- Research addendum

For use with the full Position Classification Questionnaire (PCQ) when job is in the Research job family.

PDF
Accessing the EyeMed phone app

A guide for accessing the EyeMed Members App with a few simple steps.

PDF
EyeMed Insight Plan D discount program

Beginning in 2018, EyeMed is the administrator of the University of Missouri Vision Insurance Plan. Even if you aren’t enrolled in the insurance plan for 2018, you can take advantage of the EyeMed Insight Plan D discount program. This discount option is only available to employees and their family if no one in the family is enrolled in the full service vision plan.

PDF
Registering on EyeMed.com

A guide detailing how to register online at EyeMed.com.

Excel
Snapshot of EyeMed Vision Coverage

An overview of EyeMed vision coverage for the 2018 plan year.

PDF
University of Missouri Position Classification Questionnaire

Use this form to classify a new position or reclass an incumbent or vacant position.

PDF
University of Missouri System Departmental Job Description Template

Template for writing a departmental job description

Word
University of Missouri System Global Job Description Template

Template for writing a global job description

Word
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 2017

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

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 2017

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

PDF
Flexible Benefit Summary Plan Description (SPD) for calendar year 2017

Summary plan description of the Flexible Benefit plan for 2017.

PDF
Healthy Savings Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the university Healthy Savings Plan for 2017.

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

SPD for life insurance for employees for 2017.

PDF
Long-term Disability Summary Plan Description (SPD) for calendar year 2017

Summary plan description overview of long-term disability benefits for UM System for the 2017 plan year.

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

Summary plan description for the university PPO Plan for 2017.

PDF
Retiree Health PPO Plan Summary Plan Description (SPD) for calendar year 2017

Summary plan description for the Retiree Health PPO Plan for 2017.

PDF