Employee Benefits

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Benefits Forms

	Additional Benefits Enrollment Form
	Authorization for Release of Protected Health Information
	Beneficiary Change Form - Life Insurance and AD&D
	Benefit Deduction Troubleshooting Form
	Benefit Cancellation Request
	Benefits Enrollment Information
	BlueCross BlueShield Advantage Plan
	BlueCross BlueShield Basic Plan
	BlueCross BlueShield Comprehensive Plan
	BlueCross BlueShield Medical Claim Form
	Certification of Dual Coverage for Coordination of Prescription Benefits
	Certification of Hardship Withdrawal from Elective 403(b) Contributions
	Certification of Hardship Withdrawal from Elective 457(b) Contributions
	Coordination of Prescription Benefits Claim Form
	CNA Retiree/Parent/Grandparent Enrollment Form
	CNA Enrollment Form
	Dental Coverage Summary Plan Description
	Employer's First Report of Injury or Illness Form E1 Form 122
	FMLA - Certification of Health Care Provider
	FMLA - Frequently Asked Questions
	FMLA - Intermittent Tracking Form
	FMLA - Release of Information (Family Member)
	FMLA - Release of Information (Self)
	FMLA - Request for Family and Medical Leave of Absence
	FSA Enrollment Form
	FSA Reimbursement Request Form (ASI Flex) For eligible expenses incurred for the last plan year July 1, 2006 through June 30, 2007 (and not yet reimbursed) or for the new plan year beginning July 01, 2007
	Health Care and Dental Coverage Enrollment Form
	Health Care Coverage Change Form
	Hyatt Legal Plans Certificate of Coverage
	Hyatt Legal Plan Covered Legal Services
	Hyatt Legal Plan Information
	Hyatt Legal Plan Form - New Hires
	Hyatt Legal Plans Enrollment Form
	Hyatt Legal Plan Participating Utah Attorneys
	Life Insurance - Personal Health Application
	Life Insurance Enrollment - CAMPUS
	Life Insurance Enrollment Form - HOSPITAL
	Long Term Care and AD&D Enrollment Form - Hospitals/Clinics
	Long Term Disability Enrollment Form - Hospitals/Clinics
	Long Term Disability - Hospitals/Clinics Physician Option Booklet
	Long Term Disability Enrollment Form - SOM
	Prescription Drug Coverage Information/Forms
	Request for Non-Health Related Leave of Absence
	Request for Military Leave of Absence
	Request for Extended Sick Leave Benefits
	Request for Reinstatement of Prior Service
	401(a) Retirement Plan Investment Provider Change Form
	401(a) Retirement Plan Waiver of Liability Form
	Salary Reduction Agreement - 403(b) Supplemental Retirement Plan
	Salary Reduction Agreement - 403(b) Roth Option
	Salary Reduction Agreement - 457(b) Supplemental Retirement Plan
	Separating from the University
	Summary Comparison of Health Plan Medical and Dental Options
	Travel Assistance Brochure (ADA)
	Tuition Reduction, Application for
	U Health Care Plus Advantage Plan
	U Health Care Plus Basic Plan
	U Health Care Plus Comprehensive Plan
	ValueCare Advantage Plan
	ValueCare Basic Plan
	ValueCare Comprehensive Plan
	Worldwide Assist Travel Assistance Brochure

View a Complete List of Human Resources Forms