Fillable Benefits Change Form (Southern Utah University)

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Benefits Change Form (Southern Utah University)

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SOUTHERN UTAH UNIVERSITY
Benefits Change Form
View your current elections in Self Service Banner 8, Benefits and Deductions, Health Insurance.
Employee Name _________________________________ T#___________________
Effective Date __________________ Qualifying Event ___________________________________
MEDICAL OPTIONS
[] Waive all Medical (requires proof of other coverage)
Traditional Coverage HDHP Coverage HSA (HRA option for employees not eligible for HSA)
[] Traditional Single [] HDHP Single [] Single
[] Traditional Two Party [] HDHP Family [] Family
[] Traditional Family
[] *FSA Annual Enrollment. [] *HRA Special Enrollment for employees with HDHP but are not eligible for
HSA (employer contribution only)
*FSA & HRA MUST Complete NBS Enrollment Form
DENTAL OPTIONS VISION
[] Waive all Dental [] Waive all Vision
[] Employee only [] Employee only
[] Two party [] Two party
[] Family [] Family
DEPENDENT ELECTIONS
Dependent Name Birthdate SSN Add Drop Medical, Dental, Vision
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
_________________________ _______ ___________ [] [] [] [] []
List additional dependents on separate sheet or back
OTHER COVERAGES
[] Supplemental Life Insurance may increase up 10,000 or 20,000 during open enrollment without the EOI until you
meet the guarantee coverage amount.
MUST complete Life Change Form EOI needed for changes mid-year.
[] Beneficiary changes for your life insurance must be completed on the Life Change Form.
[] AFLAC policies are short term disability, cancer, and accident. All policies are post-tax and not subject to open
enrollment. You may elect their policies at any time by calling their agent. Shellie Cox (435)229-8456
[] Retirement Personal Contributions changes can be made directly through your URS portals or with the
Fidelity/TIAA Retirement change form.
Employee Signature ________________________________________ Date _________________________
HR Signature ______________________________________________ Date _________________________
[]EMI [] Wageworks [] NBS []DEDN []BENE []BCOV []MD []DN []VS []SL [] FSA []HSA []HRA []AFL []LFD
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Benefits Change Form (Southern Utah University)

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Completed 21 July 2020

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