Employee Benefit Summaries and Forms

Please enroll or change your benefits by logging into myURHR Workday with your Active Directory. Click on ‘Benefits and Pay’ on the homepage under the Apps section, then click on ‘Change Benefits’ near the top of the page.

If you are a new hire or newly eligible you will have a task in the My Tasks section in myURHR workday that will prompt you to elect benefits.

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.

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

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

If you would like to enroll or change your HSA contributions, please log in to myURHR Workday using your Active Directory. Click on ‘Benefits and Pay’ on the homepage under the Apps section, then click on ‘Change Benefits’ near the top of the page. Select “UR Change My Health Savings Election” in the ‘Change Reason’ drop down.

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.

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.

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.

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.

To receive credit for service at another eligible institution, you must complete the retirement service credit form that is in the on-boarding tasks in myURHR Workday. If you do not complete it during that process, you will need to type in the search bar “Create Request” and click the “Create Request” result. You will then be prompted for a Request Type, select “All”, and then select “UR 403b Service Credit Request Form” and click “OK.” Complete the form entirely and click “Submit”.

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 application

To apply for the Employee Tuition Waiver Benefit (for courses taken at the UR), log into myURHR Workday using your Active Directory, click on ‘Benefits and Pay’ on the homepage under the Apps section, and then click on ‘Employee Tuition Waiver Application’ under  Suggested Links. Please contact TuitionBenefits@UR.rochester.edu for questions or concerns with your application.

Employee tuition reimbursement 

To apply for the Employee Tuition Reimbursement Benefit (for courses outside of the UR), log into myURHR Workday using your Active Directory, click on ‘Benefits and Pay’ on the homepage under the Apps section, and then click on ‘Employee Tuition Reimbursement Application’ under Suggested Links.

Employee reimbursement of professional certification/recertification exams

To apply for the Employee Tuition Reimbursement Benefit (for professional certification/recertification exams ), log into myURHR Workday using your Active Directory, click on ‘Benefits and Pay’ on the homepage under the Apps section, and then click on ‘Employee Tuition Reimbursement Application’ under Suggested Links.

NOTE: All applications must be submitted 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.

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.

Information change

To update your marital status, education, or name, log in to myURHR Workday, click on your icon in the upper right corner, click ‘View Profile’, select ‘Personal’, and then edit the different categories of personal data as needed.

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

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 log in to myURHR Workday using your Active Directory. Click on ‘Benefits and Pay’ on the homepage under the Apps section, then click on ‘Change Benefits’ near the top of the page.

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