This page contains links to various benefit enrollment and change form that may require that Adobe® Acrobat® Reader® be installed on your computer. Acrobat Reader software may be obtained free of charge at Adobe's Web site.
MEDICAL INSURANCE
| Form | Description |
| Active Employee Benefits Handbook (PDF) | Complete 2010 Benefits Handbook |
| Benefits Enrollment/Change Form | Use this form to enroll in a health plan, change health plans, or add a dependent. Supporting documentation required. |
| Life Status Change Form |
This form, in conjunction with a completed Wayne State University Benefits Program Enrollment/Change Form, is used to notify the Human Resources Department of Life Status Changes as described on the form. |
| Medical Plan Termination Form | Use this form to remove a dependent from your health plan. |
| Cash in Lieu of Medical Insurance | Two pages, plan outline and enrollment form. |
| Disabled Dependent Application and Employee Certification |
Use this form to certify eligibility for coverage for your disabled dependent. Must accompany a Medical Plan Enrollment Form (pdf) to be processed. Supporting documentation required. |
| Application for Sponsored Dependent Rider | Use this form to certify eligibility for coverage for your sponsored dependent. Must accompany a Medical Plan Enrollment Form (pdf) to be processed. Supporting documentation required. |
| Application for Senior Dependent Rider | Use this form to certify eligibility for coverage for your senior dependent rider. Must accompany a Medical Plan Enrollment Form (pdf) to be processed. Supporting documentation required. |
| PHARMACARE Member Direct Reimbursement Drug Claim Form | DMC CARE members use this form to request reimbursement for prescription drugs for which the member paid cash. |
| Pre-tax Medical Opt Out Form | Newly hired employees can use this form to decline participation in the pre-tax medical insurance plan. |
| Form | Description |
| Voluntary Vision Enrollment/Change Form | For eligible employee groups only, Vision Plan enrollment is bundled with the medical insurance that you select. However, if you have chosen the Cash-in-Lieu of medical insurance option you may enroll in the voluntary Vision Plan within 30 days of your date of hire. Use this form to enroll in the voluntary Vision Plan. Supporting documentation required. |
| EyeMed Out of Network Claim Form |
Most EyeMed Vision Care plans allow members the choice to visit an in-network or out-of-network vision care provider. You only need to complete this form if you are visiting a provider that is not a participating provider on the EyeMed network. |
| Form | Description |
| Group Life Insurance Enrollment/Change Form |
Use this form to enroll in or make changes to your life insurance coverage, enroll your dependents in the dependent life insurance plan, and update your beneficiary (-ies). |
| Group Life Certificate | The terms of the Group Life Insurance policy are contained in this document. |
| Personal Health Application | Use this form when requesting an increase your life insurance coverage. Must be accompanied by a Group Life Insurance Enrollment/Change Form (pdf) |
| Portability Application | Use this form to continue term life insurance coverage with The Hartford when you leave WSU. Please reference the Life Insurance Portability Frequently Asked Questions for additional information. |
| Notice of Conversion Privilege / Request for Quotation | Use this form to request a quote on a Universal life insurance policy with The Hartford when you leave WSU. Please reference the Life Insurance Conversion Frequently Asked Questions for additional information. |
| Form | Description |
| Use this form to enroll, change, increase and/or decrease your contribution. |
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| Enrollment Web Page | This Web page guides you through the 403(b) enrollment process. |
| Retirement Plan Highlights/Comparison | Summary comparison of the TIAA-CREF and Fidelity Investments plan. |
| TIAA-CREF Designation of Beneficiary Form | Use this form to change the beneficiary designation on existing TIAA-CREF Retirement accounts. |
| Fidelity Investments Beneficiary Designation Form | Use this form to change the beneficiary designation on existing Fidelity Investments retirement accounts. |
| Fidelity Investments Transfer Rollover Form | Use this form to move assets from another investment provider to a Fidelity retirement account. You may also use this form to consolidate multiple employer-sponsored retirement accounts currently at Fidelity. WSU Plan No. is 52864. |
| Transfer Rollover Authorization TO TIAA-CREF Form | Use this form to transfer/rollover funds to your TIAA-CREF account. |
| Hardship Withdrawal Notice and Forms | This document outlines the requirements for taking a hardship withdrawal from your retirement account. |
| Fidelity Address/Name Change Form |
Use this form to update your address or name on your Fidelity Investments account. WSU Plan No. is 52864. |
| TIAA-CREF Name Change Form |
Use this form to change your name of record on your TIAA-CREF 403(b) account. |
RETIRING FROM UNIVERSITY SERVICE
| Form | Description |
| Benefits during retirement | A summary of the various benefits available to university retirees. |
| Contact Sheet | A list of telephone numbers and Web sites for persons retiring from university service. |
| Retiree/LTD/Surviving Spouse Benefits Handbook |
Complete benefits handbook for those retired or retiring from university service. |
| Retiree Dental Plan Enrollment Form | Use this form to enroll in the dental plan for retirees. |
| Retiree Vision Plan Enrollment Form | Use this form to enroll in the vision plan for retirees. |
| Retiree Benefit Continuation Form | New retirees use this form to indicate their desire to continue medical/dental/vision benefits. |
| Retiree Benefit Continuation Form (AAUP/AFT Academic Staff Buy-Out) | New AAUP/AFT Academic Staff Retirees use this form to indicate their desire to continue their health/dental/vision benefits. |
| WSU Retiree Medical Insurance Enrollment Form (Non-Aetna) |
Retirees may use this form to enroll in the Wayne State University Medical Plans (Non-Aetna). |
| Aetna Medicare Open Plan Group Enrollment Form | New Medicare-eligible retirees and their Medicare-eligible spouses use this form to enroll in the Group Aetna Medicare Open Plan. |
| Life Insurance Change of Beneficiary Form (Retirees Only) | Retirees may use this form to change/update life insurance beneficiary (-ies). |
| Retiree AccessID Request Form | New retirees can continue to use their current AccessID by submitting this form at least two weeks prior to retirement. |
| Form | Description |
| Benefits Enrollment/Change Form | Use this form to enroll in or make changes to your dental insurance coverage. Supporting documentation required. |
| Form | Description |
| 2010 Flexible Spending Account Application | Use this form to establish a flexible spending account for 2010. |
| FSA Health Care Reimbursement Form (PDF) | Use this form to request reimbursement from your Health Care flexible spending account. |
| FSA Dependent Care Reimbursement Form (PDF) | Use this form to request reimbursement from your Dependent Care flexible spending account. |
| Form | Description |
| LTD Booklet Certificate | The terms of the Group LTD Insurance policy are contained in this document. |
| Hartford Application for Long-term Disability Income Benefits | Use this form to apply for disability benefits. This is NOT an enrollment form for disability insurance. This form is available by calling Total Compensation and Wellness at 313-577-6351. |
| Form | Description |
| Employee Tuition Assistance Application | Employees must use this form to apply for the tuition assistance benefit for academic courses taken. Fill-in online and print. (Employee benefit examples provided here) This benefit only covers the applicable tuition charge, Omnibus, Fitness Center and Registration Fees. Other fees which may be charged (e.g. course material, open and late registration, SEVIS, etc.) are the responsibility of the Employee. |
| Spouse/Child Tuition Benefit Application | The spouse and eligible dependent of an employees must use this form to apply for the reduced tuition assistance benefit for academic courses taken. |