Wayne State University

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TCW Forms

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 website.

Click here to download the Employee Benefits Handbook

Medical Insurance
 

Form Descriptio

Employee Benefit 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 Benefits Enrollment/Change Form (above form), is used to notify the Total Compensation and Wellness Department of Life Status Changes as described on the form.

Employee Benefit Plan Termination Form Use this form to remove a dependent from your health plan.
Cash in Lieu of Medical Form Use this form to enroll in Cash in Lieu
Leave of Absence Benefit Continuation Form Use this form to continue benefits while on a Leave of Absence.
Disabled Dependent Application and
Employee Certification
Use this form to certify eligibility for coverage for your disabled dependent. Must accompany a Benefits Enrollment/Change Form 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 Benefits Enrollment/Change Form 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 Benefits Enrollment/Change Form 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.


Dental Insurance
 

   

 

Employee Benefit Enrollment/Change Form

Use this form to enroll in or make changes to your dental insurance coverage. Supporting documentation required.

Delta Dental Claim Form

Use to submit an out-of-network claim.
Voluntary Dental Enrollment Form for Cash-in-Lieu of Medical Recipients This is the Dental option for persons who have cash in lieu of medical.

 

Vision Insurance
 

Form Description

Voluntary Vision Plan Enrollment Form

Use this form to enroll in the Voluntary Vision Plan. If you have not elected WSU medical insurance, you may enroll in the Voluntary Vision Plan during Open Enrollment, at time of hire or upon a Life Status Change event. Employees who are not enrolled in a WSU medical plan are eligible to choose either the Voluntary Basic or Enhanced Buy-Up Plan for their vision coverage. 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.


Life Insurance
 

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.
Medical History Information/EOI Use this form when requesting an increase your life insurance coverage. Must be accompanied by a Group Life Insurance Enrollment/Change Form
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.
Group Conversion Packet Use this form to request a quote on a Universal life insurance policy with The Standard when you leave WSU.
Life Claim Packet - Proof of Death Claim Form Use this form to file a Life Insurance claim in the event of a death of a WSU employee or their covered dependant.

 

Long-Term Disability
 

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.

 

403(b) Retirement Savings Plan
 

Form Description
403(b) Salary Reduction Agreement Use this form to adjust your payroll contribution.


457(b) Retirement Savings Plan
 

Form Description
457(b) Salary Deferral Agreement Use this form to adjust your payroll contribution.


Retiring from the University Service
 

Form Description
Retirement Benefits Fact Sheet A summary of the various benefits available to university retirees.
Contact Sheet A list of telephone numbers and websites 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).
WSU Retiree Medical Plan Termination Form Use this form to remove a dependent from your retiree health plan.
Aetna Medicare Plan (PPO) Group Enrollment Form New Medicare-eligible retirees and their Medicare-eligible spouses use this form to enroll in the Group Aetna Medicare Open Plan.
HAP Senior Plus HMO Group Enrollment Form New Medicare-eligible retirees and their Medicare-eligible spouses use this form to enroll in the Group HAP Senior Plus HMO 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
(For Skilled Trades Only)

New retirees from the Skilled Trades bargaining unit can continue to use their current AccessID by submitting this online form following their date of retirement.


Flexible Spending Accounts
 

Form Description

Flexible Spending Account Application

Use this form to establish a flexible spending account.
Health Care Reimbursement Form Use this form to request reimbursement from your Health Care flexible spending account.
Dependent Care Reimbursement Form Use this form to request reimbursement from your Dependent Care flexible spending account.


Tuition Assistance
 

Form Description
Employee Tuition Assistance Application Employees must use this form to apply for the tuition assistance benefit for each term for which benefits are requested.
Spouse/Child Reduced Tuition Application The spouse and child of an eligible employee must use this form to apply for the reduced tuition assistance benefit for each term for which benefits are requested.