Required Forms for Enrollment,
Changes, or Cancellations

Basic Medical

Form Name Form # When to Use It
Group Insurance Enrollment/Change Form FA-0820 Enrolling, changing, or canceling medical coverage.
Physician Selection Form C7-1081 When selecting the HMO or POS coverage, this form must be completed to select a primary care physician. It should be submitted with the enrollment form to the Campus Insurance Office.
UT Medical/Dental Ins Cancellation Request   To cancel medical coverage this form must be completed and submitted along with the Enrollment/Change form to the Campus Insurance Office.


Optional Special Accident

Form Name Form # When to Use It
Optional Group Special Accident Enrollment FA-0831 Enrolling, changing, or canceling optional special accident coverage.


Dental

Form Name Form # When to Use It
Group Insurance Enrollment/Change Form

FA-0820

Enrolling, changing, or canceling dental coverage.
Dentist Selection Card   When selecting pre-paid #1 or pre-paid #2 plan, this form must be completed to select a dentist. It should be submitted with the enrollment form to the Campus Insurance Office.
UT Medical/Dental Ins Cancellation Request   To cancel dental coverage this form must be completed and submitted along with the Enrollment/Change form to the Campus Insurance Office.


Optional Term Life

Form Name Form # When to Use It
Optional Term Life Enrollment Application M-95201 Enrolling in term life coverage.
Supplemental Application for Optional Life M-95202 Enrolling for coverage in excess of three times annual salary, enrolling during annual enrollment, or increasing existing term life coverage. Each covered individual must complete a separate application.
Customer Service Request L-52490 Decreasing or canceling existing term life coverage.


Optional Universal Life

Form Name Form # When to Use It
Opt. Universal Life Enrollment Application M-95090 Enrolling in universal life coverage.
Supplemental Application for Optional Life M-95202 Enrolling for coverage in excess of three times annual salary, enrolling during annual enrollment, or increasing existing term life coverage. Each covered individual must complete a separate application.
Customer Service Request L-52490 Decreasing or canceling existing universal life coverage.


Exempt Employee
Long Term Disability

Form Name Form # When to Use It
TIAA LTD Disability Enrollment HRPC 3 Enrolling or increasing long term disability coverage.
Employee's Statement of Health F4132 This statement of health is required by TIAA. The coverage effective date will be determined by TIAA after review of this statement.
Insurance Cancellation Request   Canceling existing long term disability coverage.


Non-Exempt Employee
Long Term Disability

Form Name Form # When to Use It
ITT Hartford LTD Coverage Selection HRPC11 Enrolling or increasing long term disability coverage.
Personal Health Statement GR1148 This statement of health is required by ITT. The coverage effective date will be determined by ITT after review of this statement.
Insurance Cancellation Request   Canceling existing long term disability coverage.


Miscellaneous Insurance Forms

Form Name Form # When to Use It
Group Insurance Reduction Agreement FB2 Used to exclude medical and dental premiums from the University cafeteria plan. By default, medical and dental insurance premiums are paid by the employee with "pre-tax" deductions. This waiver will cause the premiums to be paid with "after-tax" deductions.