C.O.B.R.A.

~ Informational Bulletin
~ Election Form/Monthly Rates 07-08

Life Insurance

~ FDL Beneficiary Designation
~ FDL Group Accident Insurance Certificate
~ FDL Group Life Insurance Certificate
~ FDL Life/AD&D Brochure

Prescription

~ MedCo Health Mail Order
~ MedCo Health Drug Reimbursement Form
~ Request for Extended Medication

Vision

~ Superior Vision Benefits Summary
~ Superior Vision Certificate
~ Superior Provider Nomination 

Dental

~ UT Dental Select Plan Booklet
~ UT Dental Select Information
~ UT Dental Select Claim Form
~ Assurant Benefits DHMO Plan Information 

Disability

~ Hartford LTD Information
~ Hartford STD Information
~ CNA Long Term Care Q&A
~ Standard LTD Certificate 

Other Forms

~ EGI Administrative Manual
~ EGI Employment Benefits Guide
~ EGI Zip Code Exception
~ Transfer of Insurance & Retirement Records
~ UTHSCSA Name Change 

FORMS
(click here to return to main Benefits page)

Browse through the menu below to find the appropriate form. (ORDER: Retirement, Medical, UT Flex, C.O.B.R.A, Life Insurance, Prescription, Vision, Dental, Disability, Other Forms)

Retirement

~ FY 07-08 Retiree Handbook
~ Transfer Verification
~ Purchase-Change Agreement
~ Retiree Bank Draft Consent Form
~ ORP Policies and Procedures
~ Overview of TRS and ORP
~ Request for Social Security Statement
~ TRS Benefits Handbook
~ TRS Partial Lump Sum Option
~ TRS Deferred Retirement Option Plan
~ TRS Designation of Beneficiary (TRS-11)
~ TRS Change of Address (TRS-358)
~ TRS Notice of Final Dep./Refund Req. (TRS-6)
~ Other TRS Forms
~ TSA Cancellation of Tax Sheltered Annuity
~ TSA Disclosure Form
~ TSA Purchase Agreement
~ TSA Policies and Procedures

Medical

BCBS PPO
~ Plan Booklet
~ Enrollment Guide
~ Coordination of Benefits
~ Medical Claim
~ Medical International Claim
~ Medical Transitional Benefits

UT Flex

~ UT Flex Self Service
~ Plan Booklet
~ PayFlex Reimbursement Claim
~ PayFlex Express Claim
~ Direct Deposit Authorization
~ Letter of Medical Necessity
~ PayFlex Brochure