Benefits Forms & Links

Click on the titles to view information available by Benefit

Insurance Forms & Information	Supplemental Retirement Forms & Information
Dental Insurance Forms & Information	Employee Assistance Program Information
Vision Insurance Forms & Information	Tuition Remission Forms & Information
Flexible Spending Account Forms & Information	Leave of Absence and FMLA Forms & Information
Life Insurance Forms & Information	Benefit Information when leaving the University
Long Term Disability Forms & Information

                                                                                                               If you cannot read any of these files after downloading them, please call Human Resources at ext. 7757 and request the appropriate form.

To view Summary Plan Description (SPD) information for our Health & Welfare plans please visit: http://finance.loyno.edu/human-resources/benefit-summary-plan-descriptions

Health Insurance - Blue Cross

• 2013 Medical Election Form
• Medical - Enrollment & Change Form - Sample
• Cancellation Form
• BCBS webpage
• 2013 BCBS Drug Formulary
• Medical Claim Form
• International Claim Form  - Phone: 1-800-810-2583
• Authorization Delegate Form (HIPAA)
• Prescription Claim Form
• Magellan Mental Health Link  - Phone: 1-800-991-5638
• Express Scripts New Order Form

Dental Insurance - Cigna

• Dental - Enrollment & Change Form
• Cigna Webpage
• PPO Claim Form
• PPO Summary
• PPO ID Card (generic)
• DHMO Charge Schedule

 Davis Vision 

• Davis Vision Enrollment Form
• Davis Vision Benefit Flyer
• Davis Vision Privacy Policy Notice
• DavisVision Webpage - On the member tab, enter client code 2406 under the open enrollment section  

 Flexible Spending Account(s)- Ceridian

• 2013 FSA Enrollment Form
• Direct Deposit Form
• Ceridian Benefits Webpage
• Benefit Card Information
• Additional Benefit Card Enrollment Form
• Participating Benefit Card Merchant Listings
• Sample Health Care Expense Eligibility
• Status Change Form
• Medical Reimbursement Form
• Dependent Care Reimbursement Form

Life & AD&D - Sunlife

• Life - Enrollment & Change Form - Sample
• Evidence Of Insurability Form
• Online Evidence of Insurability - Group # 90429
• Change of Beneficiary(ies) Form
• Life Conversion Kit
• Life Conversion Form
• Emergency Travel Assistance & Identity Theft Brochure
• Emergency Travel Assistance Information

Long-Term Disability - Sun Life 

• Tax Designation Form
• Sun Life - Claim Form (Physician) 
• Sun Life - Claim Form (Employee) 

 

Group Supplemental Retirement Account

• 2013 Supplemental Retirement Contribution Form 
• Choosing Your Investments Brochure
• Managing Your Accounts Online Brochure
• Marital Status Verification Form
• Online Enrollment Brochure
• TIAA-CREF Change of Address
• TIAA-CREF Roth Option Brochure 

Employee Assistance Program (EAP) - Aetna Horizon Health

• EAP Brochure

Tuition Remission

• Online Tuition Waiver Form now located on the Employee Web Services (EWS) homepage after you log in.
• Statement of Dependency (Dangling Semester)
• Tax Dependency Affidavit

FACHEX

• What is FACHEX?
• FACHEX Certification Form

Adoption Assistance

• Adoption Assistance Request

Leave of Absence

Please contact Human Resources at extension 7757 to speak to a Benefits Specialist if you may need a leave of absence.

• Leave Request Form 
• FMLA Employee Rights & Responsibilities Notice

Separation Summary

• TIAA-CREF Exit Summary
• 2013 Separation of Benefits