果冻传媒

Benefit Forms

HEALTH CARE(Please complete your benefit elections online via your MyUT portal):听

• Spousal Healthcare Eligibility Affidavit听
• Benefit Coverage Eligibility Requirements

Health Savings Account (HSA) Employee Election/Contribution Form

Health Savings Account (HSA) Employer Authorization Form

Flexible Spending Account Election Form

Flexible Spending Account Direct Deposit Form

Flexible Spending Claim Reimbursement Form

Prescription Reimbursement Form

VSP Reimbursement Form

TUITION WAIVER:

Tuition Waiver Form- To be used for employee out of state tuition (undergraduate and graduate), dependent out of state tuition (undergraduate), and all dependents of retirees.

Dependent Fee Waiver Certification-If you do not currently cover your child under any 果冻传媒 health benefit plan, please submit this听 听 听 听 听 completed form along with a copy of their birth certificate to benefits@utoledo.edu.听听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听

LIFE INSURANCE:

Main Campus Life Enrollment听听听听听听听听听听听听听听听听听听

Health Science Life Enrollment Form听听听听听听听听听听听听听听听听听听听听听

Beneficiary Change Form听