Employee Benefit Summaries and Forms

Please use one of the forms below if you are electing or changing (through a qualifying event) your health and/or dental benefits for 2021. Once you have completed and signed the form, please send in all pages of the form to Totalrewards@rochester.edu. If you are a new hire (not newly eligible) you are encouraged to enroll in your benefits online through HRMS.

• 2021 enrollment form for new hires and newly eligible employees
• 2021 enrollment form for residents and fellows
• 2021 enrollment form for members of SEIU
• 2021 qualifying event form
• 2020 qualifying event form (please use this form if your qualifying event occurred in 2020)

2021 HSA contribution form
Complete this form if you are enrolling into your HSA, updating your annual contribution to your HSA, or certifying your HSA eligibility.

Excellus young adult dependent through age 29 certification form
To enroll in Special Extended Health Care Coverage through Excellus, the employee and/or employee’s child must complete this enrollment form.

Excellus BCBS handicapped dependent form
Complete this form if you are requesting continuation of medical coverage for a disabled dependent

Excellus BCBS medical benefits claims form
Complete this form if you have a medical claim that was not completed by your provider

Dental claim form 
Complete this form if you have a dental claim that was not completed by your provider.

Lifetime Benefit Solutions direct deposit authorization form
Complete this form if you are setting up a direct deposit account for your FSA account

Lifetime Benefit Solutions FSA reimbursement request form
Complete this form if you are filing a claim for your eligible expense for your Health Care FSA or Limited Purpose FSA

Lifetime Benefit Solutions Dependent Care FSA reimbursement form
Complete this form if you are filing a claim for your eligible expense for your Dependent Care FSA

PayFlex FSA reimbursement form
Complete this form if you are filing a 2020 claim for your eligible expense for your Health Care or Dependent Care FSA

HSA contribution form
Complete this form if you are enrolling into your HSA, updating your annual contribution to your HSA, or certifying your HSA eligibility.

HSA Bank contribution form
Complete this form if you would like to contribute to HSA Bank outside of the contributions that are deducted from your University of Rochester paycheck.

HSA Bank death beneficiary form
Complete this form if you would like to add or update a Beneficiary(ies) to your HSA Bank account .

HSA Bank direct transfer request form
Complete this form to authorize HSA Bank to receive a transfer of assets directly from a Health Savings Account (HSA) into your HSA at HSA Bank.

HSA Bank rollover request form
Complete this form for an HSA Rollover involving a check.

HSA Bank name change request form
Complete and remit this form if requesting a name change. Required: Please attach supporting documentation of the name change such as a copy of a marriage certificate, divorce decree, or a court order for the name change.

University of Rochester certification of domestic partner status form
Complete this form if you are adding a Domestic Partner as a dependent to your medical or dental plan.

University of Rochester domestic partner (opposite-sex and same-sex) tax affidavit
Complete this form if you are adding a Domestic Partner as a dependent on your medical or dental plan and you require a tax affidavit.

Provider Lab Value Form
Eligible individuals that would like to receive their biometric screening numbers, but would prefer to obtain these numbers from their own doctor can provide this form to their doctor to fill out in place of attending a biometric screening clinic (Note: must be completed during current calendar year).

Fitness DVD borrowing policy form
Fill out this form if you would like to rent a fitness DVD from the Well-U Fitness DVD Library.

Fit Kit borrowing policy form
Fill out this form if you would like to rent a Fit Kit from Well-U.

Department request form
Fill out this form if you’d like to request a Well-U presentation or workshop for your department.

Group Universal Life (GUL) application
Complete this application when applying for GUL insurance.

Life insurance change request
Complete this form to change your existing life insurance coverage (You may not cancel your coverage online).

Evidence of insurability form (proof of good health)
A health history questionnaire to be completed if proof of good health is required.

Beneficiary designation form
Complete this form to add/change your beneficiaries.

Retirement service credit form
Use this form to apply for service credit towards the two-year service requirement for the University Direct Contribution to the Retirement Program.

TIAA forms
Find TIAA forms related to withdrawals, loans, beneficiary changes, etc.

Service credit form
At the University of Rochester, the service requirement for the tuition benefits plan may be met by service at another college, university or University of Rochester affiliated teaching hospital, as well as service at a member of the controlled group of the University that offered a tuition benefit plan for which the faculty or staff member was eligible. To receive credit for such prior service, please complete this form.

Employee tuition waiver
Complete the online Employee Tuition Waiver application. Apply online by logging into HRMS using your NetId and follow the path “Self Service->Benefits->Tuition->Apply Employee Tuition Waiver”. Please contact TuitionBenefits@UR.rochester.edu for questions or concerns with your application.

Employee tuition reimbursement form
Complete and submit this form to the Office of Total Rewards (TuitionBenefits@UR.rochester.edu) if you are taking courses at an outside college/university.

Employee reimbursement of professional certification/recertification exams
Complete this form and return it to the Office of Total Rewards to apply for Reimbursement of Professional Certification/Recertification Exams.

NOTE: All forms must be completed no later than 30 days from the start of the course.

Retiree qualifying event/change form
Complete this form if you are enrolling or changing your benefit elections due to a qualifying life event, such as retirement, marriage, loss of coverage, etc.

4R prior service credit form
Service requirements may be met or enhanced with the consideration of previous UR employment or employment at another higher education facility.

5R prior service credit form
Service requirements may be met or enhanced with the consideration of previous UR employment or employment at another higher education facility.

Personal data change form
Complete this form and return it to the Office of Total Rewards to update your marital status, education, or name.

Dependent information change request form
Complete this form if you need to update a dependent’s information.

Benefits program qualifying event change form
If you would like to enroll or change your benefit elections due to a qualifying life event, such as marriage, birth of a child, loss of coverage, etc., please complete and return this form.

Visit the Leave Administration page to find forms relevant to your particular leave situation.

Click the links to view more information based on your specific circumstances. Most of the links below open up PDF documentation.

• Going from full-time to part time
• Going from part-time to full-time
• Going from full-time or part-time to time-as-reported (TAR)
• On a full furlough
• Taking a leave of absence
• Layoff
• Termination
• Retirement
• Resident & Fellow layoff
• Resident & Fellow termination
• How sick time or PTO is impacted if you transfer or change status