Benefits Forms
Medical/Dental Enrollment Forms & Information
Use these forms to select or opt out of your plan for yourself and your dependents.
- 2025 Medical/Dental Group Enrollment Form (PDF)
- Affidavit of Working Spouse/Domestic Partner Insurance Status (PDF)
- Opt-Out Affidavit (PDF)
- COBRA Acknowledgement Form (PDF)
- Dependent Verification Form (PDF) - must be submitted along with supporting documentation
Plan Booklets, Plan Summaries, and Premium Charts
Get a full understanding of plan costs and details using the resources below.
- 2025 Medical Comparison Chart - Non-Faculty (PDF)
- 2025 AAUP Medical Comparison Chart - Faculty (PDF)
- 2025 Contribution Table (PDF)
- 2025 COBRA Rates (PDF)
- 2025 Full-Time Employee Benefits in Brief (PDF)
- 2025 Part-time Employees Benefits in Brief (PDF)
- 2025 Faculty Medical Mutual 85/60 Plan Booklet (PDF)
- 2025 Staff Medical Mutual 85/60 Plan Booklet (PDF)
- 2025 Medical Mutual High Deductible Health Plan Booklet (PDF)
Provider Contact Information
- Full-Time Employees' Insurance Provider Contact Information (PDF)
- Benefit Provider Contact List (website)
New Hire Information
Benefit Notifications
- Employee Privacy Notice (PDF)
- Change of Personal Information (PDF) (Add/Delete Dependents)
Dental (Delta Dental)
- Dental FAQs (PDF)
- Dental Orthodontic Services (PDF)
- Dental Claim Form for Nonparticipating Providers (PDF)
- Dental LOW Coverage Summary (PDF)
- Dental BASIC Coverage Summary (PDF)
- Dental HIGH Coverage Summary (PDF)
- AAUP High Plan (PDF)
Domestic Partner
- Domestic Partner Guidelines (PDF)
- Domestic Partner FAQs (PDF)
- Domestic Partner Important Tax Information (PDF)
- Domestic Partner Affidavit (PDF)
- Domestic Partner Termination Affidavit (PDF)
Employee Assistance Program (AllOne Health)
Health Savings Account (HSA) and Flexible Spending Accounts (PNC Bank)
- PNC Bank FSA/HSA Reimbursement Form (PDF)
- 2025 HSA Enrollment Form (PDF)
- 2025 HSA Change Form (PDF)
- 2025 FSA Enrollment Form (PDF)
- PNC Direct Transfer Form for HSAs (PDF)
Life Insurance (Securian - Minnesota Life) and Long-Term Disability (Unum)
- Basic Life and AD&D Imputed Income Example (PDF)
- Beneficiary Form - Securian (PDF)
- Evidence of Insurability (EOI) Instructions To Apply (PDF)
- Securian Basic Life and AD&D Policy Certificate (PDF)
- Securian Supplemental AD&D Policy Certificate (PDF)
- Long-Term Disability (LTD) FAQ and Calculation Flyer (PDF) - 50%
- Long-Term Disability (LTD) FAQ and Calculation Flyer (PDF) - 60%
- Long-Term Disability (LTD) Enrollment Form (PDF)
Medical Plan Summaries of Coverage and Claim Forms
- Dependent Verification Form/Instructions (PDF)
- Medical Mutual Medical Claim Form (PDF)
- Medical Mutual EOB Guide (PDF)
- Medical Mutual My Health Plan Portal
- Medical Mutual My Health Plan Flyer (PDF)
- Glossary of Health Coverage and Medical Terms (PDF)
Prescription (CVS/Caremark)
- CVS/Caremark Plan Booklet (PDF)
- CVS Health Prescription Plan Booklet (PDF)
- CVS Prescription Reimbursement form (PDF)
- Preventive Therapy Drug List for High Deductible Health Plan (PDF)
- CVS Formulary List - Prior Authorization Needed (PDF)
- Let's Talk Prescription - Preventive drug list for 85/60 and HDHP medical plans (PDF)
- Specialty Drug List (PDF)
- Medicare Part D Disclosure Notice (PDF)
Retirement Plans
- Medicare - Understanding the Basics Guide
- 403(b) Tax-Deferred Annuity Provider List (PDF)
- 457 Deferred Compensation Provider List (PDF)
- Alternative Retirement Plan (ARP) Provider List (PDF)
- Declaration of Prior State Service (PDF)
- Social Security Windfall Notification (PDF)
- Statement Concerning Your Employment in a Job Not Covered by Social Security (PDF)
- Retirement Plan Election Form OPERS/STRS (PDF) (Full-Time Faculty, Unclassified, & Classified Staff)
Tuition
- Proof of Dependency Status (PDF)
- Tuition Waiver Request for ROTC Staff, Retirees & Disabled EMPLOYEES (PDF)
- Tuition Waiver Request for DEPENDENTS of ROTC Staff, Retirees & Disabled Employees (PDF)
- Tuition Waiver Request for VSIP (Voluntary Separation) Employees and Dependents (PDF)
Vision (EyeMed)
Voluntary Supplemental Insurances
- Securian Voluntary Accidental Death & Dismemberment Certificate (PDF)
- Securian Voluntary Accidental Death & Dismemberment Policy (PDF)
- Unum Long Term Disability - Profile Access Code: ASFLKGE
Workers' Compensation
- BWC First Report of Injury (PDF)
- Employee Report of Injury or Occupational Illness (PDF)
- Safety Hazard Report (PDF)
