Insurance Forms

General Forms

Dependent Enrollment/Change Form –  Used to add or drop dependents from an employee’s/retiree’s coverage. (HR 101  07/16)

Benefit Change Form – Used to make changes to an employee’s benefits. 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  11/16)

TAMUS Dependent Child’s Statement of Disability (HR 182  07/13)

BCBSTX Disabled Child Form

Medicare Coordination Acknowledgment Form This form should be signed by retiring employees. (HR 106  09/13)

Retiree Benefit Enrollment Form – Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage. (HR 107  04/16)

Survivor Health/Dental/Vision Continuation Form  (HR 112 07/16)

Grandchild Certification Form

Tobacco User Change Form (HR 108  09/12)

Express Scripts

Express Scripts Prescription Drug Program Member Reimbursement (05/14)

Express Scripts Home Delivery Order Form (01/19)

Express Scripts Medicare Part D Claim Form (01/19)

Delta Dental

Delta Dental Group Dental Claim Form

New York Life Long-Term Disability forms

New Yok Life Claim Form

New York Life Physician Statement of Disability