• Human Resources

  • Benefit Plan Forms

    Click on the links below to download the appropriate Benefit Plans forms. If you need a form that is not listed, please call the Benefits Department at 718-430-2547.

      Your Yeshiva University Benefit Forms

    Health Insurance

    Group Health & Dental Enrollment form – use this form to enroll in or waive your health insurance. You can also use this form to add or drop dependents from your health coverage. If you are dropping or adding dependents at any time other than the annual open enrollment period, you must also complete a Family Status form.

    Qualifying Family Status form – use this form if you have a qualifying family status change and need to add or drop dependents from your plan during the plan year.

    Out-of-network Medical Claim form – use this form to submit a claim to Empire Blue Cross Blue Shield if you have used a provider that does not participate with Empire.

    Express Scripts Home Delivery Form – use this form to order your prescriptions through Express Scripts Mail order service.

    Out-of-network Blueview Vision Claim Form use this form to claim reimbursement for expenses incurred at a provider that does not participate with Blueview Vision.

     

    Dental Insurance

    Group Health & Dental Enrollment form – use this form to enroll in or waive your dental insurance. You can also use this form to add or drop dependents from your coverage. If you are dropping or adding dependents at any time other than the annual open enrollment period, you must also complete a Family Status form.

    Cigna DHMO Enrollment form use this form to elect primary dentists for yourself and your covered family members.

    Qualifying Family Status form – use this form if you have a qualifying family status change and need to add or drop dependents from your plan during the plan year.

    Cigna Out-of-network Dental Claim form - use this form to submit a claim to Cigna if you have used a provider that does not participate in the Cigna DPPO network.

    Cigna Dental Oral Health Integration Program Reimbursement form use this form to claim reimbursement for services eligible for reimbursement under the Cigna Dental Oral Health Integration Program.

    Content updated November 2014

    Reimbursement Accounts

    Health Care Reimbursement Account (HCRA) and Dependent Care Reimbursement Account (DCRA) Enrollment Form – use this form to enroll in either the HCRA or DCRA at any time other than the open enrollment period.

    Health Savings Account (HSA) Enrollment form – use this form to enroll in the HSA. You can only enroll in the HSA if you are enrolled in the Bronze Choice High Deductible Health Plan at any time other than the open enrollment period.

    Limited Use Flexible Spending Account (FSA) Enrollment Form- use this form to enroll in the Limited-Use FSA. You can only enroll in the Limited-Use FSA if you are enrolled in the Bronze Choice High Deductible Health Plan at any time other than the open enrollment period.

    TakecareWageworks Unreimbursed Medical Claim form – use this form to submit eligible health care expenses.

    TakecareWageworks Dependent Care Claim form – use this form to submit eligible dependent care expenses.

    Transportation Reimbursement & Parking Reimbursement Enrollment Form – use this form to enroll in or cancel your participation in the TRiP program.

    TakecareWageworks Transportation Reimbursement & Parking Reimbursement Claim Form use this form to claim reimbursement of eligible transit or parking expenses.

     

    Life Insurance

    Group Insurance Election form – use this form to enroll for optional life insurance coverage for yourself, your spouse or dependent children.

    Beneficiary Designation – use this form to designate a beneficiary or beneficiaries who will receive your life insurance benefits if you die.

     

    Long Term Disability Insurance

    Tax Choice Long Term Disability Election form use this form to change your election from tax free to taxable benefit or vice versa. If you are not a new hire, you may only change your election once a year during the annual open enrollment.

     

    Retirement Plans

    Basic Retirement Income Plan Salary Reduction Agreement use this form to designate a percentage of your salary that you wish to contribute to the plan. You may change your salary reduction agreement at any time.

    Basic Retirement Income Plan Catchup Contribution form use this form if you are age 50 or will turn age 50 by the end of the calendar year to elect an additional catch-up contribution to the plan. You must be contributing the maximum to the Basic Plan to be eligible to elect the catch-up contribution.

    Basic Retirement Income Plan Enrollment form use this form to make your investment elections for our contributions to the Basic Plan.

    Basic Retirement Income Plan Beneficiary Designation form use this form to designate a beneficiary or beneficiaries who will receive your retirement benefits if you die.

     

    Aflac

    Accident Indemnity Plan Reimbursement form use this form to claim reimbursement for benefits payable under the Accident Plan.

    Critical Illness Plan Reimbursement form use this form to claim reimbursement for benefits payable under the Critical Illness Plan.

    Cancer Screening Wellness Benefit Claim form use this form to claim reimbursement for eligible wellness screenings if you are enrolled in the Critical Illness Plan.

     

    Pet Assure

    Enrollment form - use this form to enroll for discounted veterinary services.

     

     

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