TSRI Benefits Administration Forms

Health & Welfare

You may add or remove a dependent in the event of a qualified Status Change. You are encouraged to review the status change definitions before downloading the form; in some cases supporting documentation is needed. You must add or remove a dependent within 31 days of the status change.

TO ADD OR REMOVE A DEPENDENT FROM YOUR COVERAGE PLEASE SELECT THE FORM THAT IS APPLICABLE TO YOUR POSITION:

Scientific and Support Staff Benefits Coverage Change Form (e.g. Professors, Technicians, Administrative Assistants) - Use this form to add or remove dependents on your medical, dental benefits.

Research Associate Benefits Coverage Change Form - Use this form to add or remove dependents on your medical, dental benefits.

Graduate Student Benefits Coverage Change Form - Use this form to add or remove dependents on your medical, dental benefits.

ADDITIONAL HEALTH & WELFARE FORMS:

Domestic Partner Affadavit - This form must be returned in addition to the applicable change form in order to add a domestic partner. You are encouraged to review the Domestic Partner Fact Sheet before adding a domestic partner.

Health Care Spending Account Reimbursement Form - Use this form to submit for reimbursement. For more information and a list of reimbursable medical expenses and over the counter expenses view Health Care Spending Account Packet

Dependent Care Spending Account Reimbursement Form - Use this form to submit for reimbursement. For more detailed information about this program view Dependent Care Spending Account Packet

Dependent Care Provider Receipt - You may download this form and present it to your Day Care Provider for signature and completion if they do not provide receipts for you.

Direct Deposit - (For Health Care and Dependent Care Reimbursements only) This form can be used to request direct deposit of reimbursements for your Health Care and/or Dependent Care Reimbursements.

Life Insurance, Group Life & AD&D Beneficiary Form - Use this form to change your beneficiaries for the group life insurance thorough ING/ReliaStar.

Medical Waiver Form - This form must be returned in addition to the applicable change form if you are refusing medical coverage from TSRI.

Prescription Mail Order Form - Use this form to order prescriptions by mail to receive a 90-day supply through this service. The mail order co-payment is $14 for generic and $30 for brand name prescriptions.

Prescription Claim Form - Use this form if you paid full-cost for your prescription and need reimbursement.

Vision Plan Form - You must bring this form with you for your routine eye exam and/or when you go to select your glasses or contacts. Check the MES link to see if your provider is part of their network

Retirement Plans

Cash Balance Retirement Plan Beneficiary Form - Use this form to change your beneficiaries for the Cash Balance Plan.

Salary Reduction Agreement 403(b) - This form changes the amount you defer to the Tax Sheltered Annuity Plan. You may change this amount once per calendar quarter and if you are a new enrollee other forms may be needed.

American Century Investments Application - Establishes a new tax sheltered annuity account at American Century.

American Funds Application - Establishes a new tax sheltered annuity account at American Funds.

Fidelity Investments Application - Establishes a new tax sheltered annuity account at Fidelity Investments.

Salary Reduction Agreement 457(b) Plan - This form changes the amount you defer to the Deferred Compensation Plan. You may change this amount once per calendar quarter and if you are a new enrollee other forms may be needed.

Miscellaneous Forms

Supervisor's Report of Work-related Injury - This form is to be used by supervisors to report any work-related injury, exposure and/or illness.

Transit Benefit Enrollment Form - Use this form to enroll in the Transit Benefit Account. This benefit allows you to reduce your taxable income by purchasing eligible transportation fares through a pre-tax payroll deduction of up to $100 per month. View Transit Benefit for more information.

Tuition Reimbursement Form - Before submitting this request, you should review the Tuition Reimbursement Policy.