The Texas A&M University System

Benefit Publications & Forms

• New Employee Benefit Enrollment Booklet (2008-09; PDF)
• Manual de inscriptión en beneficios para empleados nuevos 2008-2009
• Annual Enrollment Booklet (2008-09)
  • For employees (PDF)
  • For retirees (PDF)
    
• Plan description booklets
  • A&M Care Health Plans 08-09(PDF)
  • A&M Dental 08-09(PDF)
  • Vision (PDF)
  • Life Insurance 08-09(PDF)
  • Accidental Death and Dismemberment 08-09(PDF)
  • Long-Term Disability (PDF)
  • Long-Term Care (John Hancock's web site; username = TAMUS; = mybenefit)
  • Flexible Spending Accounts (PDF)
  • Pretax Premiums 08-09(PDF)
• Brochures
  • Benefit Program Highlights 08-09(PDF)
  • HRConnect (PDF)
  • About Disability (PDF)
  • TDAs: An Investment in Your Future (PDF)
  • A Guide to Using Your Benefits While Traveling (PDF)
  • AD&D Travel Assistance Benefit brochure (PDF)
  • When You and Your Spouse Work for the A&M System (PDF)
  • A Look Ahead: A Guide to Retiring from the A&M System (PDF)
  • A Call to Arms: A Guide to Military Leave (PDF)
  • HIPAA Notice of Privacy Practices (PDF)
  • Eldercare Guide (PDF)
• Forms
  • Insurance
  • Retirement

Insurance forms

• New Employee Benefit Enrollment Form For employees about to be hired, just hired or newly eligible for benefits by virtue of a position change. Should be completed on or before the employee's hire date, but may be completed within 60 days of hire or benefit eligibility. Employee may also need to complete the Beneficiary Designation Form and the Dependent Enrollment Form/Certification. Must be returned to employee's Human Resources office. (HR 100 7/08)
• Dependent Enrollment Form/Certification Used to add or drop dependents from an employee's/retiree's coverage. May be used in conjunction with a New Employee Enrollment or Benefit Change Form. Must be returned to employee's/retiree's Human Resources office. (HR 101 7/08)
• Annual Enrollment Form May be used during the Annual Enrollment period each year in place of the Personal Benefits Summary, which is mailed to all employees/retirees before Annual Enrollment. Must be returned to employee's/retiree's Human Resources office. (HR 102 8/08)
• Beneficiary Designation Form Used to designate and/or change a beneficiary designation for Basic Life, Alternate Basic Life, Optional Life and/or Accidental Death and Dismemberment. May be returned to the employee's/retiree's Human Resources office or the System Benefits Administration office. (HR 103 8/08)
• Benefit Change Form Used to make changes to an employee's/retiree's benefits. Must be returned to the employee's Human Resources office. To change health or dental coverage or Flexible Spending Account deductions, this form MUST be completed within 60 days of employment or eligibility for benefits or within 60 days of a Change in Status. (HR 105 8/08)
• Blue Cross/Blue Shield of Texas Disability Underwriting Transmittal Form/Dependent Child's Statement of Disability
• Medicare Coordination Acknowledgment Form Intended to provide information regarding coordination between A&M insurance plans and Medicare, this form should be signed by retiring employees. (HR 106 11/08)
• Retiree Benefit Enrollment Form Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage that does not require evidence of insurability. Must be returned to the employee's/retiree's Human Resources office. (HR 107 8/08)
• Payroll Deduction Authorization for Working Retirees (4/07)
• Caremark Physician Prior Authorization Request Form
• Caremark Prescription Drug Program Member Reimbursement Form
• Delta Dental Group Dental Claim Form
• AD&D forms
  • Fort Dearborn Claim Form for Accidental Dismemberment and/or Paralysis For accidental dismemberment and/or paralysis occurring on or after 9/1/06.
  • Fort Dearborn Claim Form for Accidental Death For accidental deaths occurring on or after 9/1/06.
  • Request for Taxpayer Identification Number and Certification For accidental deaths occurring on or after 9/1/06.
  • Fort Dearborn AD&D Conversion Form For on or after 3/04/09.
  • The Hartford Group Life and/or AD&D Claim Forms for Employee or Dependent For accidental death, loss of sight, limb loss and loss of hearing occurring before 9/1/06; includes Attending Physician's Statement.
  • The Hartford Group Life and/or AD&D Claim Forms for Employee or Dependent For paralysis occurring before 9/1/06; includes Attending Physician's Statement.
• Long-Term Care forms
  • Forms are on John Hancock's web site Username in all caps = TAMUS; Password = mybenefit
• Long-Term Disability forms
  • MetLife Long-Term Disability Claim Form (Employee Statement)
  • MetLife Long-Term Disability Claim Form (Employer Statement)
  • MetLife Long-Term Disability Attending Physician Statement
• Life insurance forms
  • Life Insurance Enrollment Form (HR 138 6/03)
  • Fort Dearborn Evidence of Insurability Form To apply for coverage, complete this form and mail to: Administrative Offices, P.O. Box 655403, Dallas, TX 75265.
  • Fort Dearborn Waiver of Premium/Accelerated Death Benefit (Living Access Benefit) Application
  • Fort Dearborn Claim Form For deaths occurring on or after Sept. 1, 2003.
  • W-9 Form For use with Fort Dearborn Claim Form in cases where the benefit is to be $25,000 or more.
  • Fort Dearborn Application to Convert Group Life Insurance
  • Fort Dearborn Application for Portability
  • TIAA/The Standard Life Insurance Benefits Application and Instructions For deaths occurring before Sept. 1, 2003.
• Survivor Health/Dental/Vision Continuation Form (HR 112 04/09)

Retirement forms

• Tax-Deferred Account Maximum Contribution Limit Worksheet To be completed by employees to calculate their maximum contribution amount to the Tax-Deferred Account plan. (HR 10 11/08)
• Prior ORP Participation Acknowledgment Form To be completed by new employees with previous eligibility or participation in the Optional Retirement Plan. (HR 11 3/08)
• ORP Information Acknowledgment Form To be completed by new ORP-eligible employees indicating receipt of information regarding the ORP. (HR 12 8/05)
• ORP/TDA Representative Acknowledgment Form To be completed by prospective authorized representatives wishing to market ORP and/or TDA Investment funds and submitted to vendors for approval. (HR 13 02/09)
• ORP Salary Reduction Acknowledgment/Change of Vendor To be completed by employees for initial election to participate in the ORP or to change ORP vendors. (HR 14 3/07)
• ORP Notification of Change in Employment Status To be completed by employees participating in ORP who transfer to another institution of higher education in Texas, terminate, retire or request a distribution upon reaching age 70 ½ (or completed by the Human Resources or Payroll office in the event of the employee's death). (HR 15 10/01)
• ORP/TDA Transfer Verification Form To be completed by employees with ORP and/or TDA accounts requesting full or partial transfers of account balance(s) to another authorized ORP and/or TDA vendor(s). (HR 16 7/06)
• TDA Salary Reduction Agreement/Change of Vendor Form To be completed by employees for initial election to participate in a TDA, to change the contribution amount, or to change a TDA vendor. (HR 17 8/07)
• Application for Participation in Early Retirement with Modified Service (ER/MS) To be completed by employees electing an early retirement/modified service start date. (HR 201 10/01)
• TDA Notification of Change in Employment Status To be completed by employees participating in TDA who terminate, retire, or request a distribution upon reaching 59½ (completed by Human Resources or Payroll office in the event of the employee's death). (HR 18 2/08)
• ORP Vesting Form To be completed by System Member Human Resources or payroll office (HR 19 2/09)

 

Questions about any of this information? E-mail us and we'll forward your message to the appropriate Human Resources office.