Medical Insurance Forms and Pamphlets - Blue Cross Blue Shield

• Enrollment Form
• Comparison Form
• Subscriber Connect
• Claim Form
• PPO
  • PPO Brochure
  • Benefit Summary
  • Plan Highlights
• DeltaCare DHMO
  • DeltaCare DHMO Brochure
  • Facility Directory
  • DeltaCare DHMO Copay Schedule

Life Insurance - Fort Dearborn (effective 1/1/08)

• Basic Life/AD&D Insurance
  • Beneficiary Designation Form
• Supplemental Life and AD&D Insurance
  • Enrollment Form
  • Highlight Sheet
  • Evidence of Insurability

Flexible Spending - Ceridian 

• 2008 Plan Year Enrollment Kit
• 2008 Automatic Claim Filing Application
• 2007 Plan Year Enrollment Kit
• Individual Forms:
  • Enrollment Form
  • Application for Automatic Claim Filing
  • Flex Direct Deposit Authorization
  • Health Expense Reimbursement Form
  • Dependent Care Reimbursement Form
• Plan Document
  

Commuter Program - Ceridian

• Enrollment Form
• Program Description

Plan Documents/Summary Plan Descriptions/Benefit Summaries

• Medical Network PPO Benefit Summary Through 5/31/07- Blue Cross Blue Shield
• Medical PPO Benefit Summary Through 5/31/07 - Blue Cross Blue Shield
• Combined DMO Summary Plan Description & Plan Document - Aetna
• Combined PPO Summary Plan Description & Plan Document - Aetna
• Dental Riders - Aetna
• California Dental DMO Rider - Aetna
• California Dental PPO Rider - Aetna
• Life Insurance - CIGNA
• AD&D Insurance - CIGNA
• Voluntary AD&D Insurance - CIGNA
• Long-Term Disability Insurance (Faculty & Administrative Officers) - The Standard
• Long-Term Disability Insurance (Staff) - UNUM
• Long-Term Disability Insurance (Staff) Plan Amendment - UNUM
• Long-Term Disability (Staff) Erisa Statement - UNUM
• Flexible Spending
• 403(b) Retirement Plan Document

Summary Annual Reports

• Life and AD&D - CIGNA - 2005
• Medical - Blue Cross Blue Shield - 2005
• Medical - Blue Cross Blue Shield - 2006
• Long-Term Disability - The Standard - 2005
• Long-Term Disability - The Standard - 2006
• Long-Term Disability - UNUM - 2005
• Long-Term Disability - UNUM - 2006
• Life and AD&D - CIGNA - 2006
• 403(b) Retirement Plan - 2005
• 403(b) Retirement Plan - 2006

Notices

• HIPAA Privacy Notice
• Initial COBRA notice
  

Tuition Remission

• Application
• Policy

Domestic Partnership Forms

• Certification of Partnership
  
• Termination of Partnership

United Way

• Charitable Contribution Form

Retirement Plan - 403(b)

• Retirement Plan Salary Reduction Agreement
• Retirement Plan IRS Maximums

• TIAA-CREF
  • Enrollment Form (Contact HR)
  • Transfer/Rollover Form (Submit Form to HR)
  • TIAA-CREF Prospectus Information
  • Beneficiary Change Form
  • Loan Information
  • Hardship Withdrawal Information
  • Online Account Registration
• Fidelity
  • Enrollment Form (Submit Form to HR)
  • Transfer/Rollover Form (Submit Form to HR)
  • Fidelity Fund/Prospectus Information
  • Beneficiary Change Form
  • Loan Information
  • Hardship Withdrawal Information
  • Online Account Registration

Accomodation Request

• Accomodation Request Form

Leave of Absence

• Request for Leave of Absence
  
• Certification of Health Care Provider
  
• Return to Work Medical Certification

Supervisor's Forms

• Justification for position
• Performance Appraisal **Updated 7/1/2007**
• Performance Appraisal (word doc) **Updated 7/1/2007**
  
• Supervisory Investigation Report
  (Employee Work-Related Injury or Illness)
  

Exit Interview

• Exit Interview
  

Link to old forms