Benefits & Wellness Forms
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For 2019: Submit this form to enroll in a health (medical/dental/vision) insurance plan, change insurance plans, or add a dependent. Be sure to also submit the 2019 Life Status Change/Benefit Termination Form during a Life Status Change Event. Supporting documentation required.
For 2020: 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. Supporting documentation required.
For 2019: To add dependents during a Life Status Change Event (Section 125 event), submit this form along with an 2019 Employee Benefit Enrollment/Change Form.
To terminate dependents during a Life Status Change Event (Section 125 event) or during Open Enrollment, submit this form.
For 2020: To add or terminate dependents during a Life Status Change Event (Section 125 event), or during Open Enrollment, submit this form.
|Submit this form to enroll in Cash in Lieu of Medical|
|Leave of Absence Benefit Continuation 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 a Employee Benefits Enrollment/Change Form to be processed. |
Supporting documentation required.
|Application for Sponsored Dependent||Use this form to certify eligibility for coverage for your sponsored dependent. Must accompany a Employee Benefits Enrollment/Change Form to be processed. |
Supporting documentation required.
|Pre-tax Medical Opt Out Form||Newly hired employees can use this form to decline participation in the pre-tax medical insurance plan.|
|Use this form to enroll in or make changes to your dental insurance coverage. If you have Cash in Lieu of Medical, use Voluntary Dental Plan Enrollment Form (below). Supporting documentation required.|
|Use to submit an out-of-network claim.|
|This is the Dental option for persons who have Cash in Lieu of Medical.|
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 at time of hire, during Open Enrollment, or upon a Life Status Change Event. Employees who are not enrolled in a WSU medical plan are eligible to choose either the Basic or Enhanced Buy-Up Plan for their 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 dependant.|
|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 get started with the new 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||The spouse and/or 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.|
|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.|
|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 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.|
|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 (Non-Medicare).|
|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.|