{"id":15756,"date":"2020-01-09T12:07:03","date_gmt":"2020-01-09T17:07:03","guid":{"rendered":"https:\/\/www.rochester.edu\/human-resources\/?page_id=15756"},"modified":"2026-06-24T12:05:11","modified_gmt":"2026-06-24T16:05:11","slug":"employee-benefits-summaries-forms","status":"publish","type":"page","link":"https:\/\/www.rochester.edu\/human-resources\/benefits\/employee-benefits-summaries-forms\/","title":{"rendered":"Employee Benefit Summaries and Forms"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":6,"featured_media":0,"parent":176,"menu_order":99999,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":"","_members_access_role":[],"_members_access_error":""},"class_list":["post-15756","page","type-page","status-publish","hentry"],"acf":{"lead_in":"","display_title":"","subtitle":"Get comprehensive plan details and specific forms relevant to your benefits.","call_to_action":"","hero_image_placement":"right_image","hero_media":"images","hero_pattern_option":"","hero_video":"","hero_image_landing":"","hero_image_landing_two":"","hero_image_landing_three":"","content_modules":[{"acf_fc_layout":"text","anchor":"","css_class":"pb-20","title":"

Forms, documents, and summaries<\/h2>","content":"

Need to make changes, complete paperwork, or simply want more information about your plan? Reference the forms and summaries<\/a> below for more guidance.<\/p>","background_color":"#ffffff","width":"width-medium"},{"acf_fc_layout":"accordion","anchor_id":"forms","classes":"","title":"

Employee benefits enrollments\/changes<\/strong><\/h2>","description":"If you are unsure about whether or not you need to submit a form, or which form you need to complete, please\u00a0contact Human Resources<\/strong><\/a>. Most of these links drive to PDF documents for you to download and print when appropriate.","layout":"center","width":"width-medium","background_color":"#f4f4f4","style":"row_simple","row_bg_color":"","row_text_color":"#252525","row_bg_color_hover":"#252525","row_text_color_hover":"","row_border_color":"#252525","row_border_weight":"normal-border","animation":"","icon":"chevron-icon","icon_location":"right-icon","accordions":[{"title":"Health care and dental enrollment\/contributions","row_content":"Please enroll or change your benefits by logging into myURHR Workday<\/a> with your Active Directory. Click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, then click on \u2018Change Benefits\u2019 near the top of the page.\r\n\r\nIf you are a new hire or newly eligible you will have a task in the My Tasks section in myURHR workday that will prompt you to elect benefits.","accordion_anchor":""},{"title":"Young adult dependent through age 29 certification form","row_content":"Excellus young adult dependent through age 29 certification form<\/a>\r\nTo enroll in Special Extended Health Care Coverage through Excellus, the employee and\/or employee\u2019s child must complete this enrollment form.","accordion_anchor":""},{"title":"Health care and dental handicapped dependent forms","row_content":"Excellus BCBS handicapped dependent form<\/a>\r\nComplete this form if you are requesting continuation of medical coverage for a disabled dependent","accordion_anchor":""},{"title":"Health care and dental claims","row_content":"Excellus BCBS medical benefits claims form<\/a>\r\nComplete this form if you have a medical claim that was not completed by your provider.\r\n\r\nDental claim form\u00a0<\/a>\r\nComplete this form if you have a dental claim that was not completed by your provider.\r\n\r\nPrescription Drug claim form<\/a>\r\nComplete this form to submit your prescription drug claim.","accordion_anchor":""},{"title":"Flexible Spending Account (FSA)","row_content":"Lifetime Benefit Solutions direct deposit authorization form<\/a>\r\nComplete this form if you are setting up a direct deposit account for your FSA account\r\n\r\nLifetime Benefit Solutions FSA reimbursement request form<\/a>\r\nComplete this form if you are filing a claim for your eligible expense for your Health Care FSA or Limited Purpose FSA\r\n\r\nLifetime Benefit Solutions Dependent Care FSA reimbursement form<\/a>\r\nComplete this form if you are filing a claim for your eligible expense for your Dependent Care FSA","accordion_anchor":""},{"title":"Health Savings Account (HSA)","row_content":"If you would like to enroll or change your HSA contributions, please log in to myURHR Workday<\/a> using your Active Directory. Click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, then click on \u2018Change Benefits\u2019 near the top of the page. Select \u201cUR Change My Health Savings Election\u201d in the \u2018Change Reason\u2019 drop down.\r\n\r\nHSA Bank contribution form<\/a>\r\nComplete this form if you would like to contribute to HSA Bank outside of the contributions that are deducted from your 糖心传媒 paycheck.\r\n\r\nHSA Bank death beneficiary form<\/a>\r\nComplete this form if you would like to add or update a Beneficiary(ies) to your HSA Bank account.\r\n\r\nHSA Bank direct transfer request form<\/a>\r\nComplete this form to authorize HSA Bank to receive a transfer of assets directly from a Health Savings Account (HSA) into your HSA at HSA Bank.\r\n\r\nHSA Bank rollover request form<\/a>\r\nComplete this form for an HSA Rollover involving a check.\r\n\r\nHSA Bank name change request form<\/a>\r\nComplete and remit this form if requesting a name change. Required: Please attach supporting documentation of the name change such as a copy of a marriage certificate, divorce decree, or a court order for the name change.","accordion_anchor":""},{"title":"Domestic partner forms","row_content":"You will need to provide a\u00a0Certification of Domestic Partner Status form\u00a0<\/a> with a copy of your Certificate of Domestic Partnership granted by the\u00a0City of Rochester<\/a>\u00a0or your local municipality.\r\n\r\nIf your Domestic Partner is considered a taxable dependent, you will also need to provide the\u00a0Tax Affidavit form<\/a>.","accordion_anchor":""},{"title":"Well-U forms","row_content":"Provider Lab Value Form<\/a>\r\nEligible individuals that would like to receive their biometric screening numbers, but would prefer to obtain these numbers from their own doctor can provide this form to their doctor to fill out in place of attending a biometric screening clinic (Note: must be completed during current calendar year).\r\n\r\nDepartment request form<\/a>\r\nFill out this form if you'd like to request a Well-U presentation or workshop for your department.","accordion_anchor":""},{"title":"Life insurance","row_content":"Group Universal Life (GUL) application<\/a>\r\nComplete this application when applying for GUL insurance.\r\n\r\nLife insurance change request<\/a>\r\nComplete this form to change your existing life insurance coverage (You may not cancel your coverage online).\r\n\r\nEvidence of insurability form<\/a> (proof of good health)\r\nA health history questionnaire to be completed if proof of good health is required.\r\n\r\nBeneficiary designation form<\/a>\r\nComplete this form to add\/change your beneficiaries.","accordion_anchor":""},{"title":"Retirement","row_content":"To receive credit for service at another eligible institution, you must complete the retirement service credit form that is in the on-boarding tasks in myURHR Workday<\/a>. If you do not complete it during that process, you will need to type in the search bar \u201cCreate Request\u201d and click the \u201cCreate Request\u201d result. You will then be prompted for a Request Type, select \u201cAll\u201d, and then select \u201cUR 403b Service Credit Request Form\u201d and click \u201cOK.\u201d Complete the form entirely and click \u201cSubmit\u201d.","accordion_anchor":""},{"title":"Tuition benefits","row_content":"Service credit form<\/a>\r\nAt the University of Rochester, the service requirement for the tuition benefits plan may be met by service at another college, university or 糖心传媒 affiliated teaching hospital, as well as service at a member of the controlled group of the University that offered a tuition benefit plan for which the faculty or staff member was eligible. To receive credit for such prior service, please complete this form.\r\n\r\nEmployee tuition waiver application<\/strong>\r\n\r\nTo apply for the Employee Tuition Waiver Benefit (for courses taken at the UR), log into myURHR Workday<\/a> using your Active Directory, click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, and then click on \u2018Employee Tuition Waiver Application\u2019 under \u00a0Suggested Links. Please contact TuitionBenefits@UR.rochester.edu<\/strong><\/a>\u00a0for questions or concerns with your application.\r\n\r\nEmployee tuition reimbursement\u00a0<\/strong>\r\n\r\nTo apply for the Employee Tuition Reimbursement Benefit (for courses outside of the UR), log into myURHR Workday<\/a> using your Active Directory, click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, and then click on \u2018Employee Tuition Reimbursement Application\u2019 under Suggested Links.\r\n\r\nEmployee reimbursement of professional certification\/recertification exams<\/strong>\r\n\r\nTo apply for the Employee Tuition Reimbursement Benefit (for professional certification\/recertification exams ), log into myURHR Workday<\/a> using your Active Directory, click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, and then click on \u2018Employee Tuition Reimbursement Application\u2019 under Suggested Links.\r\n\r\nNOTE: All applications must be submitted no later than 30 days from the start of the course.<\/strong>","accordion_anchor":""},{"title":"Retiree benefits","row_content":"5R prior service credit form<\/a>\r\nService requirements may be met or enhanced with the consideration of previous UR employment or employment at another higher education facility.","accordion_anchor":""},{"title":"Making changes","row_content":"Information change<\/strong>\r\n\r\nTo update your marital status, education, or name, log in to myURHR Workday<\/a>, click on your icon in the upper right corner, click \u2018View Profile\u2019, select \u2018Personal\u2019, and then edit the different categories of personal data as needed.\r\n\r\nDependent information change request form<\/strong><\/a>\r\nComplete this form if you need to update a dependent\u2019s information.\r\n\r\nIf you would like to enroll or change your benefit elections due to a qualifying life event, such as marriage, birth of a child, loss of coverage, etc., please log in to myURHR Workday<\/a> using your Active Directory. Click on \u2018Benefits and Pay\u2019 on the homepage under the Apps section, then click on \u2018Change Benefits\u2019 near the top of the page.","accordion_anchor":""},{"title":"Leave Administration forms","row_content":"Visit the Leave Administration page<\/a> to find forms relevant to your particular leave situation.","accordion_anchor":""}]},{"acf_fc_layout":"interstitial","anchor_id":"","classes":"","layout":"layout_stacked","lead-in":"Still have questions?","title":"We're here to help","content":"Contact Human Resources to get answers to your questions.","call_to_action":{"title":"Contact us","url":"https:\/\/www.rochester.edu\/human-resources\/contacts\/","target":""},"bg_color":"#00205b"},{"acf_fc_layout":"card_grid","anchor":"summaries","css_class":"center-text ","title":"

Find your plan summary<\/h2>","description":"

Download full PDF overviews of the benefits available to you based on your role at the University of Rochester. See legal notices related to these benefits<\/a>.<\/p>","background_color":"#FFFFFF","width":"width-large","columns":"3","cards":[{"card_title":"Faculty and staff new hire guide<\/strong>","card_text":"A comprehensive benefits reference guide for newly hired faculty and staff in 2026","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/07\/faculty-staff-new-hire-packet.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"SEIU new hire guide<\/strong>","card_text":"A comprehensive benefits reference guide for newly hired SEIU members in 2026","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/06\/new-hire-packet-seiu.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Staff benefits summary<\/strong>","card_text":"For full- and part-time staff members","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/01\/Staff-Benefits-Summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Faculty benefits summary<\/strong>","card_text":"For full- and part-time faculty members","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/01\/Faculty-Benefits-Summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Resident and fellow benefits summary<\/strong>","card_text":"For regular full- and part-time residents and fellows","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/01\/Resident_Fellow-Benefits-Summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Active SEIU member benefits summary<\/strong>","card_text":"For current members of SEIU","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2024\/07\/seiu-benefits-summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Postdoctoral associate and fellow benefits summary<\/strong>","card_text":"For postdoctoral associates and fellows","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2023\/01\/PostDoc-Benefits-Summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Time-as-reported staff benefits summary<\/strong>","card_text":"For time-as-reported (TAR) employees","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [PDF]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2024\/07\/tar-benefits-summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Travel at Home benefits summary<\/strong>","card_text":"For travel at home employees","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"View plan summary [pdf]","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2024\/07\/travel-at-home-benefits-summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"In-House Staffing benefits summary<\/strong>","card_text":"For in-house staff","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2024\/02\/in-house-staffing-benefits-summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""},{"card_title":"Faculty Senior Associates Program benefits summary<\/strong>","card_text":"For faculty senior associates","card_background_color":"#f4f4f4","card_hover_color":"#283faf","card_link":{"title":"","url":"https:\/\/www.rochester.edu\/human-resources\/wp-content\/uploads\/2024\/12\/fsap-benefits-summary.pdf","target":""},"card_hover_arrow":"","card_image":"","card_image_size":"","card_image_placement":"","card_image_hover_state":"hover_fade","card_image_link":""}]},{"acf_fc_layout":"accordion","anchor_id":"","classes":"","title":"

Summary of benefits upon a change in status<\/h2>","description":"Understand how benefits change when your employment status changes, such as if you go from full-time to part-time.","layout":"center","width":"width-medium","background_color":"#f4f4f4","style":"row_simple","row_bg_color":"","row_text_color":"#252525","row_bg_color_hover":"#252525","row_text_color_hover":"","row_border_color":"#252525","row_border_weight":"normal-border","animation":"","icon":"chevron-icon","icon_location":"right-icon","accordions":[{"title":"See how your benefits are impacted","row_content":"Click the links to view more information based on your specific circumstances. Most of the links below open up PDF documentation.\r\n