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Employee Benefit Summaries and Forms

Get comprehensive plan details and specific forms relevant to your benefits.

Forms, documents, and summaries

Need to make changes, complete paperwork, or simply want more information about your plan? Reference the forms and summaries below for more guidance.

Employee benefits forms

If you are unsure about whether or not you need to submit a form, or which form you need to complete, please contact Human Resources. Most of these links drive to PDF documents for you to download and print when appropriate.

Health care and dental enrollment/contributions

Please use one of the forms below if you are electing or changing (through a qualifying event) your health and/or dental benefits for 2023. Once you have completed and signed the form, please send in all pages of the form to If you are a new hire (not newly eligible) you are encouraged to enroll in your benefits online through HRMS.

Young adult dependent through age 29 certification form

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.

Health care and dental handicapped dependent forms

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

Health care and dental claims

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.

Prescription Drug claim form
Complete this form to submit your prescription drug claim.

Flexible Spending Account (FSA)

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

Health Savings Account (HSA)

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.

Domestic partner forms

You will need to provide a Certification of Domestic Partner Status form with a copy of your Certificate of Domestic Partnership granted by the City of Rochester or your local municipality.

If your Domestic Partner is considered a taxable dependent, you will also need to provide the Tax Affidavit form.

Well-U forms

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).

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

Life insurance

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.

Tuition benefits

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 for questions or concerns with your application.

Employee tuition reimbursement form
Complete and submit this form to the Office of Total Rewards ( 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 benefits

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.

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.

Making changes

Personal data change form
Complete this form 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.

Leave Administration forms

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

Summary of benefits upon a change in status

Understand how benefits change when your employment status changes, such as if you go from full-time to part-time.

Benefits glossary

Get term definitions

See in-depth explanations for terms frequently used within the details of your benefits package. Understand definitions and see examples.

Visit glossary

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