Benefit & Wellness Forms
Insurance
Use
Coverage Change Form (PDF 113KB)
Submit to Benefits to add or drop a dependent and/or change coverage within 31 days of qualifying event
Claim Form-Dental (PDF 31KB)
Submit a dental claim to Delta Dental for reimbursement if your dentist does not file the claim
Claim Form-Humana (PDF 198KB)
Submit a health claim to Humana for reimbursement if your provider does not file the claim
Prescription Mail Order-RightSource (PDF 249KB)
Order a 3-month supply of your prescription via mail order
HSA Contribution Change (PDF 809KB)
Submit to Benefits to change the amount you contribute to your HSA per pay period
HSA Beneficiary Designation (PDF 221KB)
Submit to United Missouri Bank (UMB) to designate a beneficiary for your HSA
HSA Eligibility Form (PDF 56KB)
Complete and submit to Benefits upon electing the HDHP with HSA in order for any funds to be deposited into your HSA
HSA Deposit Slip (PDF 93KB)
Redeposit money mistakenly withdrawn from your HSA; rollover or transfer money from another HSA
Long Time Disability (PDF 255KB)
Eligible for LTD benefit after off work due to illness or accident for 180 days. You may apply before the 180 days has expired.
Spouse/SSDPartner Certification Form (PDF 78KB)
This form must be completed annually if electing health coverage for a spouse or same-sex domestic partner. The employee, spouse/partner, and employer (if applicable) must complete the form and return it to Miami University Employee Benefits & Wellness in order to be covered if eligible within 31 days of hire or qualifying event.
Flexible Spending Accounts
Use
Benny Debit Card Substantiation (PDF 34KB)
Submit to Chard Snyder upon request to verify that your Benny Card usage was for an eligible expense
Change of Status Request (PDF 64KB)
Submit to Benefits within 31 days of any change (qualifying event)
Direct Deposit Authorization (PDF 30KB)
Submit to Chard Snyder if you wish your reimbursements be made via direct deposit into your personal bank account
Claim Reimbursement Request (PDF 55KB)
Submit to Chard Snyder with receipts to request reimbursement from your FSA
Life Insurance
Use
Beneficiary Change Form (PDF 1.02MB)
Submit to Benefits when you want to change your beneficiary for group life, group accidental death, or voluntary life and/or voluntary accidental death
Evidence of Insurability (PDF 120KB)
Complete and submit to Liberty Mutual when you enroll in the voluntary life coverage for the first time during open enrollment or if you elect more than $350,000 coverage for yourself
Submit to Benefits within 31 days of a qualifying event in order to change or cancel your voluntary coverage
Retirement
Use
ARP Vendor Change Form (PDF 38KB)
Employees who chose an ARP may change their retirement vendor at any time by completing, signing, dating and submiting this form to Benefits
Retirement Plan Election Form (PDF 199KB)
New employees who choose an ARP, must set up their ARP account with the vendor and complete, sign, date and submit this form to Benefits
Same-Sex Domestic Partner (SSDP)
Use
Affidavit of Same-Sex Domestic Partnership (PDF 52KB)
Submit to Benefits to establish your SSDPartnership for benefit purposes
Affidavit of Termination of SSDP Status (PDF 57KB)
Submit to Benefits within 31 days of termination of partnership
Taxability of SSDP Benefits (PDF 106KB)
Submit to Benefits to demonstrate that your SSDP qualifies as a tax dependent
Tuition Fee Waiver
Use
Tuition Fee Waiver Dependent Affidavit (PDF 93KB)
Once you have applied for the fee waiver for a child, you must have this form notarized or attach the front page of your previous year's federal income tax form and submit to Benefits