Benefit Forms

Healthcare Plans

Delta Dental Claim Form

Health/Dental/Vision Insurance Change

Humana Claim Form

Humana RightSource New Customer Registration and Prescription Order

Humana RightSource Provider Fax Order Form (for the provider's use)

Humana Provider Nomination

HSA Employee Contribution Change

HSA Beneficiary Designation

HSA Eligibility

HSA Deposit Slip

 

Life Insurance

Beneficiary Change Form for Life Insurance

Evidence of Insurability (Liberty Mutual)

Voluntary Life and Group Accident Insurance Cancellation/Change

 

Flexible Spending Accounts

Employee Reimbursement Request Form

Benny Debit Card Substatiation Form

Direct Deposit Authorization

Change of Status Request

 

Annuities 403(b) and 457

Annuity Salary Reduction Cancellation

 

Retirement Plans

Alternative Retirement Plan Vendor Change

Retirement Plan Election

 

Same-Sex Domestic Partner Benefits

Affidavit of Same Sex Domestic Partnership

Affidavit of Termination of Domestic Partner Status

Taxability of Domestic Partner Benefits

 

Tuition Fee Waiver

Tuition Fee Waiver Request

 

Benefit Services
15 Roudebush Hall
(513) 529-3926
(513) 529-4223 FAX

 

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