Benefit Forms
Benefits Enrollment Form
Benefits Change Form
Dependent Information Request Form
Prescription Drug Program
Caremark Mail Order Request Envelope
Caremark Retail Prescription Drug Claim Form
Caremark Identification Card
Vision Care Insurance
EyeMed Vision Care Out-of-Network Claim Form
Life, Accidental Death & Dismemberment, and Dependent Life Insurance
Assurity Life Insurance Statement of Health Form
Assurity Life Insurance Beneficiary Designation Form (Standard)
Assurity Life Insurance Beneficiary Designation Form (Trust)
Long Term Care Insurance
Long Term Care Employee Enrollment Form
Long Term Care Short Form Application
Long Term Care Long Form Application
Reimbursement Account
Reimbursement Account Claim Form
Supplemental Reimbursement Account Claim Form
Letter of Medical Necessity for Dual Purpose OTC Drugs
Retirement Plan
Record of Prior Service for Basic Retirement Plan Participation
Basic Retirement Plan Tier Election Form
Retirement Plan Allocation Change Form for Basic Contributions
Supplemental Tax-Sheltered Annuity 403(b) Program Pre-Tax Salary Reduction/Roth Deduction Agreement
Deferred Compensation 457(b) Plan Salary Reduction Agreement
Loan Program Summary/Application for Loan Form
TIAA-CREF SRA 403(b) Retirement Plan Enrollment Form
TIAA-CREF 457(b) Deferred Compensation Plan Enrollment Form
TIAA-CREF Beneficiary Form
Fidelity Investments SRA 403(b) Retirement Plan Application
Fidelity Investments 457(b) Deferred Compensation Plan Application
Fidelity Investments Beneficiary Form
3835 Holdrege Street, Lincoln, Nebraska 68583 | 402.472.2111 |