Benefits Forms

• COBRA BANK DRAFT AUTHORIZATION
• COBRA COUPON PAYMENT BOOK
• COBRA NOTIFICATION
• COBRA PREMIUM RATES FOR 2013
• DENTAL CHOICE CLAIM FORM (Call 1-877-377-0987)
• DISABILITY CLAIM FORM
• HUMANA DENTAL SELECTION FORM
• DRUG REIMBURSEMENT FORM (Call 1-888-886-8490)
• ELECTION TO GO TO ORP
• EVIDENCE OF INSURABILITY FORM (EOI) FOR DISABILITY INSURANCE
• EVIDENCE OF INSURABILITY FORM (EOI) FOR LIFE INSURANCE
• EMPLOYEE CHECKLIST FOR EOI
• FML CERTIFICATION OF HEALTH CARE PROVIDER (FOR SELF/EMPLOYEE)
• FML CERTIFICATION OF HEALTH CARE PROVIDER (FOR FAMILY MEMBER)
• FMLA APPLICATION (UH)
• GBP SUPPLEMENTAL FORM
• HEALTH SELECT CLAIM FORM
• CAREMARK MAIL ORDER FORM
• PRIOR STATE SERVICE FORM
• SALARY REDUCTION AGREEMENT
• TEX FLEX
• TRS REQUEST FOR REFUND
• TRS BENEFICIARY DESIGNATION FORM
• TRS CHANGE OF ADDRESS
• TRS WEBSITE (MY TRS) AUTHORIZATION