TSRI Logo

Benefits

spacer

Forms

  1. Health and Welfare Change Forms
  2. Medical/Prescription/Mental Health/Vision Forms
  3. Health Care and Dependent Care Spending Account Forms
  4. Delta Dental Forms
  5. Retirement Plan Forms
  6. Other Benefit Forms

 

Health and Welfare Change Forms

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. Proof of a status change is required. You must also provide proof of dependency if adding a dependent to the plan. For more information on what documentation to provide, click here.

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.
California
Florida

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

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

Medical/Prescription/Mental Health/Vision Forms

Aetna Medical Reimbursement Form

HMO Primary Care Physician Designation Form (California HMO Participants only)

EPO Primary Care Physician Designation Form (Florida EPO Participants only)

Medical Waiver Form (All Medical Plans)

Aetna Prescription Mail Order Form (HMO/EPO Participants only)

Aetna Transition Care Request Form (CA HMO Only)

Aetna Transition Care Request Form (CA PPO/HDHP/Grad Only)

On-Line Claims Reimbursement for a Non-United Behavioral Health Provider (PPO/High Deductible/TSRI Grad Students and External Grad Students only)

United Behavioral Health Reimbursement Form (PPO/High Deductible/TSRI Grad Students and External Grad Students only)

Medical Eye Services Vision Claim Form (California Participants only)

Flexible Spending Account Forms

All FSA claims are filed online at www.Tri-Ad.com

Delta Dental Forms

Delta Dental Reimbursement Form

Retirement Plan Forms

Cash Balance retirement plan forms

Cash Balance Beneficiary Designation Form

Deferred Compensation (457(b)) Retirement Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Faculty and Management Retirement (401(a)) Retirement Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Transfer/Rollover/Exchange Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Fidelity Distribution Rollover Form

Employee retirement (401(a)) plan forms

Fidelity Investments Beneficiary Designation Form

Tax Sheltered Annuity (403(b)) Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Transfer/Rollover/Exchange Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Fidelity Distribution Rollover Form

Other Benefit Forms

Injury Report-- CA ONLY

Prudential Group Term Life Beneficiary Form

Transit Benefit Enrollment Form

Prudential Voluntary Life/AD&D Beneficiary Form