Forms and Publications

For Plan Year Beginning September 1, 2011

 

Insurance Benefits List | Retirement Programs List

You will need Adobe Reader to view the following PDF files. You may view these documents in your browser window or download them to your hard drive. If you need assistance with forms please contact your local Benefits Office.

 

• View Plan Guides Only
• Group Benefits Handbook for Employees
• Group Benefits Handbook for Retired Employees
• Office of Employee Benefits Administrative Manual
• Notice of Privacy Policies and Procedures

MEDICAL - Blue Cross and Blue Shield of Texas

• UT SELECT Benefits Summary Chart
• UT SELECT Medical Benefits Guide
• Your UT SELECT Health Benefits at a Glance
• Blue Care Connection Flyer
• Medical Claim Form
• Tobacco Cessation and Weigt Management Programs
• Condition Management Programs

PHARMACY - Medco

• Prescription Drug Program at a Glance
• Medco by Mail Order Form
• Prescription Drug Reimbursement Form
• Coordination of Benefits/Direct Claim Form

DENTAL

• UT SELECT DENTAL Benefits Guide Delta Dental
• UT SELECT DENTAL Claim Form Delta Dental
• UT SELECT DENTAL Benefits Brochure Delta Dental
• Finding a Dentist Flyer Delta Dental
• Your Plan and the DPO Network Delta Dental
• Meet the Smyles - Oral Health Information for Children Delta Dental
• The connection between your oral and overall health Delta Dental
• SmileWaySM Wellness Program: Take the Challenge Delta Dental
• Assurant Dental HMO Option Booklet Assurant Employee Benefits
• Assurant Dental Evidence of Coverage Assurant Employee Benefits

VISION - Superior Vision

• Superior Vision Benefits Guide
• Provider Nomination Form
• Superior Vison Claim Form
• Superior Vision Benefits Brochure
• Getting Started with the Online Member Portal
• Smart Alert - Partnering for Total Wellness
• SVContacts.com - Online Contact Lens Ordering
• Finding-In-Network Providers

UT FLEX - PayFlex Systems

• UT FLEX Benefits Guide
• Payflex Quick Reference Guide
• UT FLEX Claim Form
• Direct Deposit Authorization Form
• Letter of Medical Necessity Form
• The PayFlex Debit Card
• Flexible Spending Accounts (FSA) Brochure

LIFE & ACCIDENTAL DEATH and DISMEMBERMENT(AD&D) Dearborn National

• Group Term Life Benefits Guide
• Accidental Death & Dismemberment Benefits Guide
• Portability and Conversion of Life Insurance
• Life Conversion Application
• Life Portability Application
• Death Claim Form
• Accelerated Death Claim Form
• Waiver of Premium Claim Form
• Accidental Dismemberment Claim Form
• Life/AD&D Benefit Highlights for Active Employees
• Life Benefit Highlights for Retired Employees
• About Online Beneficiary Management
• Beneficiary Designation Form
• AD&D Enhancements
• Create Your Own Will Online
• Freedom Account
• Beneficiary Resource Services

SHORT TERM DISABILITY (STD) - Fort Dearborn Life

• Short Term Disability Benefits Guide
• Short Term Disability Highlights
• Blue Care Link for Short Term Disability
• Filing Your STD Claim

LONG TERM DISABILITY (LTD) - Fort Dearborn Life

• Long Term Disability Benefits Guide
• Long Term Disability Benefit Highlights
• LTD Employee Claim Form
• LTD Employer Claim Form
• LTD Conversion Kit
• LTD Conversion Calculator

LONG TERM CARE (LTC) - CNA

• LTC Enrollment Form for New Employees
• LTC Short Form Application - For current Employees and Spouses
• LTC Long Form Application - For all other applicants
• Long Term Care Guide
• Long Term Care Highlights
• Why You Should Consider Long Term Care
• Introducing Long Term Care

SPECIAL NOTICES

• Early Retiree Reinsurance Program (ERRP) Notice and Q&As
• Notice of Creditable Coverage (NOCC)
• Notice of Privacy Policies and Procedures
• Medicaid and the Children's Health Insurance Program (CHIP) Notice

OTHER

• Benefits Cost Worksheet for EMPLOYEES
• Benefits Cost Worksheet for RETIRED EMPLOYEES
  
• Chapter 1601 of the Texas Insurance Code
  
• Office of Employee Benefits Organizational Chart
  
• HIPAA Privacy Information
  
• HIPAA Security of Electronic Protected Health Information (PHI) COMPLIANCE MANUAL

Retirement Programs

Investment Policy Statement

Optional Retirement Program

• ORP Plan
• Overview of TRS and ORP
• Transfer Verification Form - Use to transfer balances from one provider to another
• TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program) - The TRS 28 must be completed by all participants making their initial ORP election.
• TRS Form 29 (Application for Refund) - Use only if you have an account balance with TRS
• UT Vesting/Termination Status Form

UTSaver Tax-Sheltered Annuity Program

• UTSaver TSA Plan
• Loan, Hardship and Unforseeable Emergency Procedures
• Transfer Verification Form - Use to transfer balances from one provider to another

UTSaver Deferred Compensation Plan

• Purchase Agreement for Annual Leave Deferral
• UTSaver DCP Policy
• Loan, Hardship and Unforseeable Emergency Procedures
• Transfer Verification Form - Use to transfer balances from one provider to another.
• Special Catch-Up Provision Disclosure - This must be signed if utilizing the Special Catch-Up Provision and must be accompanied by a calculation sheet.

Forms to download if you do not wish to use UTRetirement Manager

If you are making an initial ORP election, you must also complete the TRS 28 form listed at the top of this page.

• Purchase/Change Agreement - Use to change provider(s) for future retirement contributions
• Authorization for Reduction for Employee Contribution - Use for initial ORP election
• Authorization for Reduction for Employee Contribution for Employees Returning to ORP - Use for ORP election for vested participants returning to employment
• ORP Acknowledgement Form - Must be signed by all employees who are newly-eligible for ORP
• Tax-Sheltered Annuity Disclosure - This must be signed before your enrollment into a TSA is effective

Your Benefits Office can help you complete these forms.