Benefits & Wellness Forms
Due to the pandemic and our current work from home environment, you are strongly encouraged to submit forms to:
E-mail: firstname.lastname@example.org. Please note: use your WSU E-mail and include "#SECURE" in the subject line to ensure your personal information is encrypted. If you're not using WSU E-mail, be sure to encrypt your message.
Submit this form to enroll in a health (medical/dental/vision) insurance plan, or change insurance plans. Be sure to also submit the Life Status/Open Enrollment Change Form during a Life Status Change Event.
To add or terminate dependents' coverage or to terminate coverage altogether during a Life Status Change Event or Open Enrollment, submit this form.
|Submit this form to enroll in Cash in Lieu of Medical.|
|FMLA/Leave of Absence Benefit Continuation Application Form||Submit this form to continue benefits while on a Leave of Absence.|
|Disabled Dependent Application|| |
Use this form to certify eligibility for coverage for your disabled dependent. Must accompany an Employee Benefits Enrollment/Change Form to be processed.
Use this form to enroll in or make changes to your Dental Plan. If you have not elected WSU medical insurance, you may enroll in the Voluntary Dental Plan at time of hire, during Open Enrollment, or upon a Life Status Change Event.
|Use to submit an out-of-network claim.|
|Employee Benefit Enrollment Form|| |
Use this form to enroll in or makes changes to your Vision Plan. If you have not elected WSU medical insurance, you may enroll in the Voluntary Vision Plan at time of hire, during Open Enrollment, or upon a Life Status Change Event. You are eligible to choose either the Basic or Enhanced Buy-Up Plan for your vision coverage.
|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.
|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 beneficiaries.|
|Group Life Certificate||The terms of the Group Life Insurance policy are contained in this document.|
|Evidence of Insurability Application|| |
Submit this application to Sun Life Financial when requesting an increase your life insurance coverage.
Must also submit a Basic and Supplemental Life/AD&D Enrollment/Change
|Portability Kit||This kit will help guide you through the Portability process.|
|WSU fills this out for you (upon your request) during the portability process.|
|Portability Application||Use this form when applying for portability through Sun Life Financial.|
|Conversion Kit||This kit will help guide you through the Conversion process.|
|WSU fills this out for you (upon your request) during the conversion process.|
|Conversion Application||Use this form when applying for conversion through Sun Life Financial.|
|Death Benefits Claim Packet||Use this form to file a Life Insurance claim in the event of a death of a WSU employee or their covered dependent.|
|LTD Booklet Certificate||The terms of the Group LTD Insurance policy are contained in this document.|
|Employee Application for Long-term Disability Income Benefits||Use this form to apply for disability benefits. This is NOT an enrollment form for disability insurance.|
|Physician's Statement of Disability|
|403(b) Salary Reduction Agreement||Full-time employees, use this form to adjust your 403(b) payroll contributions.|
|Part-Time Faculty 403(b) Salary Reduction Agreement||PART-TIME FACULTY ONLY - use this form to adjust your 403(b) payroll contributions.|
|457(b) Salary Deferral Agreement||Full-time employees, use this form to adjust your 457(b) payroll contributions.|
|Use this form to establish a flexible spending account.|
|Out-of-Pocket Reimbursement Request Form||Use this form for reimbursement of any out-of-pocket expenses (Medical and/or Dependent Care) where your Discovery Benefits debit card was not used.|
|Recurring Dependent Care Request Form||This form is to be completed each plan year and as changes occur when the participant wants to receive recurring reimbursement of dependent care expenses.|
|Employee Tuition Assistance Application - NOW ONLINE - NO PAPER|| |
To use the online application, simply do the following:
Once you access the link you will select the semester, click the course/s that we should apply the tuition award to, and then follow the system prompts until you hit the submit button on the final page.
|Spouse/Child Reduced Tuition Application - NOW ONLINE - NO PAPER|| |
To use the online application, simply have your employee Access ID (i.e. aa1111) ready and go to: https://tuitionbenefit.apps.wayne.edu/dependents
Once you access the link you will click the 'dependents' button, click the semester that the Reduced Tuition for Spouse/Child benefit should be applied to, carefully read the questions and follow the system prompts, sign the online request, and click the 'agree' button to finalize your request.
|FMLA/Leave of Absence Benefit Continuation Application Form||Use this form to continue benefits while on leave of absence.|
|Physician's Report on Illness||To return to work, the employee will have this form filled out by the attending physician or surgeon. Refer to WSU Administrative Policies Procedures and/or applicable Collective Bargaining Agreement for specific guidelines.|
|FMLA Claim Submission Checklist||Step-by-step instructions on what you need to do to apply for an FMLA leave.|
|Provider Qualification Form (PQF)||Submit this form in place of completing the on-campus biometric screening to enroll in the Wellness Warriors program.|
|Flu Shot Consent Form||Bring this consent form with you to your on-campus flu shot.|
|Retirement Benefits Fact Sheet||A summary of the various benefits available to university retirees.|
|Benefits Resource Directory||A helpful list of contact information for each vendor WSU utilizes for benefits.|
|The benefits handbook for those retired or retiring from university service, long-term disability recipients and surviving spouses.|
|Retiree, Surviving Spouse and Long-Term Disability Recipient Benefits Enrollment Forms||The book of enrollment forms for those retired or retiring from university service, long-term disability recipients and surviving spouses.|
|New retirees, surviving spouses or long-term disability recipients use this form to indicate their intent to continue medical, dental and/or vision benefits (THIS IS NOT AN ENROLLMENT FORM).|
|Retiree Benefit Intent 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 (THIS IS NOT AN ENROLLMENT FORM).|
|Use this form to enroll in, change or terminate retiree dental plan coverage.|
|Use this form to enroll in, change or terminate retiree vision plan coverage.|
|Retirees, surviving spouses and long-term disability recipients use this form to enroll in a Wayne State University medical plans.|
|Use this form to remove a dependent from your retiree health plan.|
|New Medicare-eligible retirees and their Medicare-eligible spouses use this form to enroll in the Group Aetna Medicare Plan (PPO).|
|New Medicare-eligible retirees and their Medicare-eligible spouses use this form to enroll in the Group HAP Senior Plus HMO Plan.|
|Retirees and long-term disability recipients use this form to edit life insurance beneficiaries.|