BENEFITS FORMS

Claim Forms

• Blue Cross Blue Shield-TX Claim Form  
• Prescription Drug Reimbursement Form
• Delta Dental Claim Form
• Superior Vision Non-Network Claim Form (Microsoft Word) (PDF)
• FLEXBEN UT FLEX Day Care Claim Form (For Plan Year Sep. 1, 2003 - Aug. 31, 2004) (PDF)
• FLEXBEN UT FLEX Medical Claim Form (For Plan Year Sep. 1, 2003 - Aug. 31, 2004) (PDF)
• PayFlex UT FLEX Claim Form (For Plan Year Sept. 1, 2004 - Aug. 31, 2005) (PDF)

Beneficiary Designation Forms

• Fort Dearborn Life Insurance Beneficiary Designation Form
• TRS Beneficiary Designation Form (PDF)

Evidence of Insurability Forms

• Medical Plan
• Life Insurance Plan
• Long Term Disability Plan
• Short Term Disability Plan

Other Important Forms

• Prescription Drug Mail Order Form (PDF)
• PayFlex 2004-2005 UT FLEX Direct Deposit Authorization Form (PDF)
• Change In Status Form For Mid-Year Benefit Election Changes (PDF)

   
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