Forms

Please make a selection from the menu below:

1. Generic Forms and Notices
2. Dental
3. Medical
4. Vision
5. Group Term Life
6. Long Term Disability

Employee Forms and Notices

1. Continuation of Coverage for Disabled Dependents Form PDF
2. Language Assistance Program Notice (for CA groups) PDF
3. HIPAA Notice English | Spanish
4. Termination Form (for terming an employee's coverage) Word | PDF
5. COBRA Form PDF

DENTAL

1. UT Universal Employee Enrollment Form PDF
2. Dental Group Roster (to enroll more than one employee) Word | Excel
3. English Dental Only Enrollment Form Online | Word | PDF
   
4. Spanish Dental Only Enrollment Form Word | PDF
5. English Dental/Vision Enrollment Form Online | Word | PDF
6. Spanish Dental/Vision Enrollment Form Word | PDF
   
7. Affidavit of Domestic Partnership Form Word | PDF
8. Dental Claim Form PDF

MEDICAL

Health Solutions II - Medical Co-pay

1. Health Solutions II Enrollment Form (National) Online | Word | PDF
2. Health Solutions II Enrollment Form (Texas) Online | Word | PDF
3. Health Solutions II Enrollment Form (Arizona) PDF
4. UT Universal Employee Enrollment Form PDF
5. Idaho Universal Enrollment Form (for all medical plans) Online | PDF
6. Group Medical Claim Form PDF
7. Caremark Mail Order Form PDF
8. View a Current Drug List PDF
   
9. Caremark Prescription Drug Claim Form PDF
   

Health Solutions I - HDHP

1. HDHP Employee Enrollment Form Online | Word | PDF
2. HDHP Employee Enrollment Form (Texas) Online | Word | PDF
3. HDHP Employee Enrollment Form (Arizona) PDF
4. UT Universal Employee Enrollment Form PDF
5. Idaho Universal Enrollment Form (for all medical plans) Online | PDF
6. Group Medical Claim Form PDF
7. Caremark Mail Order Form PDF
8. View a Current Drug List PDF
   
9. HDHP Prescription Drug Claim Form PDF

VISION

1. English Enrollment Card Online | Word | PDF
2. Spanish Enrollment Card Word | PDF
3. UT Universal Employee Enrollment Form PDF
4. Vision Claim Form PDF
   

GROUP TERM LIFE

1. Gold, Silver and Bronze Life Enrollment Form Word | PDF
2. Essential Life Enrollment Form Word | PDF
3. Passport Life Enrollment Form Word | PDF
   
4. Flex Life Enrollment Form Word | PDF
5. Group Term Life Roster (to enroll more than one employee) PDF
   
6. Change of Beneficiary Word | PDF
7. Employee Death Benefits Claim Form PDF
8. Dependents Death Benefits Claim Form PDF
9. AD&D Claim Form PDF
10. Accelerated Benefits Claim Form PDF
11. Waiver of Premium Claim Form PDF

LONG TERM DISABILITY

1. Long Term Disability Enrollment Form Word | PDF