| Form Name |
Available
Formats
(Icon Legend) |
Form Descriptions |
|
Blue Cross Health Care Claim Form |
 |
For Blue Cross health care claims. |
|
Caremark Prescription Claim Form |
|
For Caremark pharmacy claims. |
|
COBRA Rights and Responsibilities Summary |
|
Summary of COBRA Rights and Responsibilities. |
|
Financially
Interdependent Partners Explanation |
|
To explain and determine FIP eligibility. |
|
Financially
Interdependent Partners Statement |
|
To declare FIP eligibility. |
FML: Q & A's
|
|
Questions and answers regarding Family Medical Leave (FML). |
| FML
Request Form |
|
To request FML leave for a serious health condition
(to be completed by employee). |
| FML: Certification of Health Care Provider for Employee's Serious Health Condition |
External Site
|
To support an employee's FMLA leave request due to the employee's own serious health condition (to
be completed by the employee, employer, and the employee's health care provider). |
| FML: Certification of Health Care Provider for Family Member's Serious Health Condition |
External Site
|
To support an employee's FMLA leave request due to a family member's serious health condition (to
be completed by the employee, employer, and the family member's health care provider). |
| FML: Certification of Qualifying Exigency for Military Family Leave |
External Site
|
To support an employee's FMLA leave request due to a qualifying military exigency (to be completed by the employee and employer). |
| FML: Certification for Serious Injury or Illness of Covered Servicemembers - for Military Family Leave |
External Site
|
To support an employee's FMLA leave request due to the serious health condition of a covered servicemember (to be completed by the employee or covered servicemember, employer, and DOD health care provider). |
|
FSA Claim
For Medical And Dependent Care Form |
|
To submit a claim for your flexible spending
account. |
| FSA
Direct Deposit For Medical And Dependent Care Form |
|
To establish direct deposits of flexible
spending account payments. |
| Student
Enrollment Verification/Dependent Health Care Eligibility |
|
To verify student enrollment and/or to notify
employees of dependent (child) health care coverage eligibility. |
UA Choice Enrollment Guide
(For coverage effective as of July 1, 2009.) |
|
UA Choice Enrollment Guide for plan period of July 1, 2009, through June 30, 2010. |
UA
Choice Health Plan Enrollment Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.) |
|
To enroll employee and dependents
in the UA health care plan for the plan period of July 1, 2009, through June 30, 2010. |
UA
Choice Opt Out Form - FY10
(For plan period of July 1, 2009, through June 30, 2010.) |
|
To elect to opt out of UA health care coverage during the plan period of July 1, 2009, through June 30, 2010. |
UA
Choice Supplemental Benefit Election Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.) |
|
To add or delete employee selected benefits
and/or deductions (e.g. FSA, AD&D, Supplemental Life) during the plan period of July 1, 2009, through June 30, 2010. |
UA Supplemental Life Evidence of Insurability (EOI) Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.) |
|
Employees electing more than $200,000 in supplemental life coverage are required to complete the evidence of insurability form and submit it to their HR office along with with the UA Choice Supplemental Benefit Election Form. |
| VSP
Out-of-Network Reimbursement Form |
|
Effective 7/1/04: To submit a claim to VSP
(vision vendor) for out-of-network provider reimbursements. |
