Forms and Publications

Insurance Benefits List | Retirement Programs List

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Benefit Changes Beginning September 1, 2009 - NEW Quick Summary

Group Benefits Handbook for Employees

Group Benefits Handbook for Retired Employees

Office of Employee Benefits Administrative Manual

MEDICAL - Blue Cross and Blue Shield of Texas

• UT SELECT Benefits Summary Chart
• UT SELECT Benefits Guide
• Your UT SELECT Health Benefits at a Glance
• Medical Claim Form
• Tobacco Cessation
• Weight Management
• Prescription Drug Program at a Glance Medco Health
• Medco by Mail Order Form Medco Health
• Prescription Drug Reimbursement Form Medco Health
• Coordination of Benefits/Direct Claim Form

DENTAL

• Assurant Dental HMO Option Booklet Assurant Employee Benefits
• Assurant Dental Evidence of Coverage Assurant Employee Benefits
• UT SELECT DENTAL Benefits Guide Delta Dental
• UT SELECT DENTAL Claim Form Delta Dental
• UT SELECT DENTAL Brochure Delta Dental
• Finding a Dentist Flyer Delta Dental
• Your Plan and the DPO Network Delta Dental

VISION - Superior Vision

• Superior Vision Benefits Guide
• Provider Nomination Form
• Superior Vision Benefits Brochure
• Getting Started with the Online Member Portal
• Smart Alert - Partnering for Total Wellness
• SVContacts.com - Online Contact Lens Ordering
• Vision Care Learning Center
• The Superior Difference
• #1 In Customer Service

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) Fort Dearborn Life

• Group Term Life Benefits Guide
• Accidental Death & Dismemberment Benefits Guide
• Life/AD&D Benefit Highlights for Active Employees
• Life Benefit Highlights for Retired Employees
• Beneficiary Designation Form

SHORT TERM DISABILITY (STD) - Fort Dearborn Life

• Short Term Disability Benefits Guide
• Short Term Disability Highlights
• Blue Care Link

LONG TERM DISABILITY (LTD) - Fort Dearborn Life

• Long Term Disability Benefits Guide
• Long Term Disability Highlights

LONG TERM CARE (LTC) - CNA

• Long Term Care Guide
• Long Term Care Highlights
• Why You Should Consider Long Term Care
• Introducing Long Term Care

Other

• 2009-2010 Benefits Cost Worksheet
  
• Transitional Benefits Form
  
• Chapter 1601 of the Texas Insurance Code
  
• Notice of Creditable Coverage (NOCC)
• Optional Retirement Program (ORP) Certification Form
  
• Office of Employee Benefits Organizational Chart
  
• HIPAA Privacy Information
  
• HIPAA Security of Electronic Protected Health Information (PHI) COMPLIANCE MANUAL

Retirement Programs

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.