HRM Benefits: Benefit Forms

Text Version

Monday, November 23, 2009 01:14:35 AM

Summary of Tax Saver Flexible Benefits Plan

	Benefit Forms Definity Health Insurance Claim Form Definity Health Prescription Drug Claim Form Definity Health Summary Plan Description for 2003/2004 Plan Year Dental Insurance Change Form (Ameritas) Dental Insurance Claim Form (Ameritas) Dental Insurance Enrollment Form and Informational brochure (Ameritas)
	Flexible Spending Account Reimbursement Form Flexible Spending Enrollment / Change Form Health Insurance/ Prudential Life Insurance/ COBRA Election Form (GB-01) Health Insurance Late Applicant Enrollment Forms (due by 14th of the month previous to desired effective date): GB-01 Acknowledgement of Pre-existing Condition and Statement of Physical Condition Insurance Portability Law Application (do not need to complete if you have a Certificate of Prior Coverage Insurance Acknowledgement Form for New Employees Leave Without Pay Benefits Continuation/Cancellation Form (GI-1) Long Term Disability Claim Forms (The Hartford) Long Term Disability Late Application (The Hartford) Long Term Disability Conversion Forms (The Hartford) Return to Work Application (re-hired retirees of the Teacher's Retirment System) Separation from LSU (continuation of benefits and retirement account rollover/ distribution) Status Change Form (to be completed along with GB-01) UNUM Life/ Long Term Care Change Form (American Heritage, New York Life, Reliastar, Provident) Vision Change Form Vision Enrollment Form Retirement Forms Louisiana Deferred Compensation Plan (DCCL) Enrollment Forms Retirement Forms Salary Reduction Agreement for 403(b) and 457(b) Plans

Benefits Service Center
Office of Human Resource Management
304 Thomas Boyd Hall
Louisiana State University
Baton Rouge, Louisiana 70803
Phone: 225/578-8200
Fax: 225/578-5981

Internet 2 University Member