Benefit Forms
Benefit forms have been organized by:
- General
- Medical
- Dental
- Leaves of Absence and Workers’ Compensation
- Flexible Spending Accounts
- Illness, Injury, and Life Benefits
- Retirement
- Educational Assistance
- Retiree Medical
- Domestic Partnership
These forms can be downloaded as Microsoft Word documents or as PDFs using Adobe Acrobat reader. Click here for more information about Using Adobe Acrobat Reader.
| General Benefits Forms | ||
| Benefits Enrollment Form | ||
| Maroon Plan | ||
| Claim Form | BCBSIL | |
| Humana Premier HMO | ||
| Select your Primary Care Physician | ||
| HMO Illinois | ||
| Select your Primary Care Physician | ||
| UCHP | ||
| Select your Primary Care Physician | ||
| MetLife Dental PPO Plan | ||
| Claim Form | MetLife | |
| MetLife Dental Copay Plan | ||
| Claim Form | MetLife | |
Leaves of Absence and Workers’ Compensation
| Accrual Use Option (WC) | MS Word | |
| Certification of Health Care Provider (FMLA) | MS Word | |
| Employee Statement of Injury/Illness – Workers’ Compensation | MS Word | |
| Faculty and Academic Leave of Absence Benefit Information Form | MS Word | |
| Family and Medical Leave of Absence Policy Statement | MS Word | |
| Family and Medical Leave of Absence Request Form | MS Word | |
| Personal Leave of Absence Request Form | MS Word | |
| Release of Medical Information (WC) | MS Word | |
| Request for Short-Term Disability Leave | MS Word | |
| Request for Treatment Form 100 (WC) | MS Word | |
| Supervisor’s First Report – Workers’ Compensation Claim of Injury/Illness | MS Word | |
| Workers’ Compensation Rights and Responsibilities | MS Word | |
Flexible Spending Accounts (FSAs)
| Health Care and/or Dependent Care FSA | ||
|
Health Care Reimbursement Account Request for Change in Status Form |
MS Word | |
|
Dependent Care Reimbursement Account Request for Change in Status Form |
MS Word | |
| Claim Forms | WageWorks | |
| Qualified Transportation Program (QTP) | ||
| Enrollment Application & Payroll Deduction Authorization | Please contact WageWorks.com to register | |
| Reimbursement Form | Please contact WageWorks.com to register | |
Illness,
Injury, and Life Benefits
| Long-Term Disability | ||
| Employee's Statement of Health | UNUMProvident | |
| Claim Form | ||
| Group Life Insurance | ||
| Employee's Statement of Health | UNUMProvident | |
| Claim Form | ||
| Personal Accident Insurance | ||
| Claim Form | ||
| Retirement Plans Change of Contribtuion Allocation Form | MS Word | |
| Retirement Income Plan for Employees (ERIP) | ||
| ERIP Application | MS Word | |
| Enrollment Form for TIAA and CREF Group Retirement Annuity Certificates with Delayed Vesting | TIAA-CREF | |
| Vanguard | ||
| Lump-Sum Distribution from Defined Benefit Portion Election Form | MS Word | |
| Special IRS Tax Notice Regarding Plan Payments | MS Word | |
| Contributory Retirement Plan (CRP) | ||
| CRP Application | MS Word | |
| Enrollment Form for TIAA and CREF Group Retirement Annuity Certificates with Delayed Vesting | TIAA-CREF | |
| Vanguard | ||
| Supplemental Retirement Program (SRP) | ||
| Salary Reduction Agreement | MS Word | |
| Enrollment Form for TIAA and CREF Group Supplemental Retirement Annuity Certificates | TIAA-CREF | |
| Vanguard | ||
| Tuition Assistance Program | ||
| Staff Tuition Assistance Application at the University of Chicago | MS Word | |
| Staff Tuition Assistance Application Outside of the University of Chicago | MS Word | |
| Employee Child Application - Lab School | MS Word | |
| Staff Child Application - The College | MS Word | |
| Application for Faculty Children's Scholarship | MS Word | |
| Retiree Medical Plan | ||
| Enrollment Form | MS Word | |
| Claim Form | BCBSIL | |
| Statement of Domestic Partnership Form | MS Word | |
| Visiting Personnel Information Sheet | MS Word | |
| Statement of Termination of Domestic Partnership Form | MS Word | |
UHRM® 
The University of Chicago®
University Human Resources Management
956 East 58th St., Chicago, IL 60637
773-702-8900