Benefits Forms and Information

Benefits Summary (Benefits in Brief)

• Benefits FAQs
  
• Full-Time Employees 
• Part-Time Employees 
  

Customer Service Contact Information

• Full-time Employees' Insurance Provider Contact Information
  
• Part-time Employees' Insurance Provider Contact Information
  

Dental

• Delta Dental FAQs
  
• Delta Dental PPO Summary of Benefits
• Delta Dental DHMO Summary of Benefits
  
• Delta Dental Enrollment/Change Form
• Delta Dental Orthodontic Services
  
• Delta Dental Claim Form for Nonparticipating Providers
• 2013 Delta Dental LOW Coverage Summary
• 2013 Delta Dental BASIC Coverage Summary
• 2013 Delta Dental HIGH Coverage Summary
  

Domestic Partner

• Domestic Partner Guidelines
  
• Domestic Partner FAQs
  
• Domestic Partner Important Tax Information
  
• Domestic Partner Affidavit
  
• Domestic Partner Termination Affidavit
  

Flexible Spending Accounts 

• 2011 Important Changes to FlexSave Benefits
  
• Flexible Spending Account Enrollment Form 2013
• Flexible Spending Account Summary Plan
  
• Flexible Spending Account Worksheet
  
• FLEXSAVE Dependent Care Reimbursement Form
  
• FLEXSAVE Spending Account Claim Form

Life Insurance

• Basic Life Insurance and AD&D Enrollment Form
  
• Booklet for Standard Life Insurance
  
• Beneficiary Change Form
  
• Medical History Questionnaire (Online Completion)
  
• Medical History Questionnaire (Printable pdf.)
  

Medical

• Adult Dependent Child Enrollment Form
• Anthem Claim Form
• Anthem Plan Booklet
• Dependent Verification Form/Instructions
• Health Care Reform
  
• Medical Mutual Medical Claim Form
• Medical Mutual Plan Booklet
• Medical Mutual EOB Guide
• Medical Mutual My Health Plan Portal
  
• Summary of Benefits and Coverage IMPACT Employee Assistance Program
• Summary of Benefits and Coverage Plan 90/70
• Summary of Benefits and Coverage Plan 80/60
• Summary of Benefits and Coverage Plan 70/50
• Glossary of Health Coverage and Medical Terms

• 2013 Medical Plan Information and Forms
  
• • 2013 Group Insurance Enrollment Form - Part-Time
  • 2013 Group Insurance Enrollment Form - Full Time
  • Medical Plans Comparison Chart 2013
  • Opt-Out Affidavit 2013
  • 2013 Medical and Dental Contribution Tables - Full-Time
  • Adult Dependent Child Enrollment Rates 2013
  • COBRA Rates Chart 2013

New Hire Orientation

• New Hire Presentation

Prescription

• 2013 CVS/Caremark Plan Booklet
• Caremark Prescription Reimbursement Form
  
• Medicare Part D Disclosure Notice
  

Retirement Programs

• 403(b) Tax Deferred Annuity Provider List
  
• 457 Deferred Compensation Provider List
  
• Alternative Retirement Plan (ARP) Provider List
  
• Declaration of Prior State Service (.doc)
  Declaration of Prior State Service (.pdf)
  
• OPERS Personal History Record
  
• Salary Reduction Agreement for Tax Deferred Annuity and/or Deferred Compensation
  
• Social Security Windfall Notification
  
• Statement Concerning Your Employment in a Job Not Covered by Social Security (.doc)
  Statement Concerning Your Employment in a Job Not Covered by Social Security (.pdf) 
• Transaction Authorization Form
  
• Retirement Plan Election Form OPERS/STRS  (Full-Time Faculty, Unclassified, & Classified Staff)
  

Tuition

• Proof of Dependency Status
  
• Tuition Benefit Request for ROTC Staff, Retirees & Disabled Employees
  
• Tuition Benefit Request for Dependents of ROTC Staff, Retirees & Disabled Employees
  

Vision

• EyeMed Vision Plan Booklet
  
• EyeMed Vision Provider List
  
• EyeMed Vision Claim Form 

Voluntary Group Long-Term Disability

• Long-Term Disability Enrollment Form
  
• Voluntary Long Term Disability Summary