Benefits Forms and Documents

General Forms

Benefits Enrollment Form
Employee Health Insurance Responsibility Disclosure (HIRD) Form
Flexible Benefit Plan Mid-Year Changes Certification Statement
Section 125 Cafeteria Plan Compensation Reduction Agreement for Commonwealth Connector Plan
W-4 Form

Charts & Schedules

2012 Contributions – Health, Dental, Life and Accident Plan
Health Plan Comparison
Dental Blue Freedom Plan Fee Schedule
Dental Health Center Plan Fee Schedule

Health Plan Forms

BCBS Subscriber Submit Claim
Medco Health Home Delivery Prescription Drug Order Form
Medco Member Brochure

Dental Health Plan Forms

BCBS Dental Claim Form

Reimbursement Accounts

Dependent Care Reimbursement Account Claim Form
Health Care Reimbursement Account Claim Form
List of Eligible Health Care Reimbursement Account Expenses

Survivor Insurance (Life and Accident Insurance)

Designation of Beneficiary Form for Survivor Benefits
Group Life Evidence of Insurability Statement

Long-Term Disability Plan

Long Term Disability Plan Waiver

Retirement and Supplemental Retirement and Savings Plans

Your Scenario

Forms You Must Complete

You are enrolling in the Boston University Retirement Plan or the Supplemental Retirement and Savings Plan for the first time.

Note: Please read the TIAA/CREF Prospectuses prior to completing a TIAA/CREF application.

You are already participating in the Supplemental Retirement and Savings Plan and wish to change the amount of your contribution.

You are already participating in the Boston University Retirement Plan or the Supplemental Retirement and Savings Plan and wish to direct contributions from Fidelity to TIAA/CREF or vice versa.

Note: Please read the TIAA/CREF Prospectuses prior to completing a TIAA/CREF application.

You currently are not participating in the Boston University Retirement Plan or the Supplemental Retirement and Savings Plan (and wish to reinitiate participation) but have existing accounts with Fidelity and/or TIAA/CREF through Boston University.

You wish to change your beneficiary designation for the Boston University Retirement Plan or Supplemental Retirement Savings Plan.

You are no longer a BU employee and wish to withdraw your funds or transfer to another 403(b) or IRA.

Tuition Forms

Tuition Remission Application Form
Tuition Exchange Application Form

Benefits Handbook (Plan Descriptions)

Administrative Information
Dental Health Plan
Flexible Benefits Plan
Health Plan
Long-Term Disability Plan
Other Benefits
Retirement Plan
Supplemental Retirement & Savings Plan
Survivor Insurance
Tuition Remission Program
Tuition Exchange
Complete Benefits Handbook (40MB download)