University of St. Thomas : Human Resources : Benefits Forms

Benefits Forms

Quicklinks to topics in this section
Dental	Disability
Family Medical Leave Act	Health Care & Dependent Care Reimbursement
Health Savings Account	Life Insurance / AD&D
Medical	Retirement
Tuition Remission	Vision
Workers Comp

Dental/Medical

2013 Benefits Election Form
Dependent Eligibility Matrix
HIPAA Form
BCBS Claim Form
Delta Claim Form

Disability

Sun Life and FMLASource Brochure
Fitness for Duty Certification
Reasonable Accommodation Request Form - Employee
Reasonable Accommodation Request Form - Physician
LTD Taxable or Non-taxable Premium Form

Family Medical Leave Act

Sun Life and FMLASource Brochure

Health Care & Dependent Care Reimbursement

Medical and Daycare Expense Claim Form
HIPAA
Direct Deposit Authorization

Health Savings Account

HSA Enrollment Packet
HSA Account Design Change Form
HSA Distribution Request Form
HSA Claim and Web Instructions

Life Insurance/AD&D

Sun Life Beneficiary Designation Form
Sun Life Evidence of Insurability Form
Sun Life Voluntary Life and AD&D Enrollment Form
Optional Life Waiver Form

Retirement

2013 Salary Reduction Agreement Voluntary 403(b) Form
Fidelity Change of Beneficiary
TIAA-CREF Change of Beneficiary
Carrier Change Form

Tuition Remission

Undergraduate Application
Graduate Application
ACTC Application

Vision

Out of Network Vision Services Claim Form

Worker's Comp

Accident/Incident Form
Physician's Report/Work Status

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University of St. Thomas

Benefits Forms

Benefits Forms