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This is NOT an enrollment form. You must enroll online using My UT Benefits during Annual Enrollment or, for new Employees at institutions not participating in My UT Benefits Initial Enrollment, through your institution’s Benefits Office.
Please remember that this form only provides you (the subscriber) with an estimate of your total out-of-pocket cost per month based on state-appropriated funds and contracted premium rates. Be sure to review available benefits materials for more information on the plans listed.