Benefit Forms
The following forms should be forwarded to Human Resources (unless noted by the form), One Bear Place 97053, Waco, TX 76798-7053.
Medical Forms:
- Benefits Enrollment Application/Change Form
- Medical Claim Form (submit to address on the form)
- Medical/Dental Insurance Continuation (COBRA) Form
Prescription Drug Forms:
- Mail Service Prescription Form (submit to address on the form)
- Reimbursement Claim Form (submit by fax to CVS/Caremark)
Dental Forms:
- Benefits Enrollment Application/Change Form
- Dental Claim Form (submit by fax to DR dental plan)
Flexible Spending Account:
- Flexible Spending Account Enrollment Application/Change Form
- Unreimbursed Medical/Dental Claim Form
- Dependent Day Care Claim Form
- Direct Deposit Authorization Form
Miscellaneous Forms:
- Cancellation of Supplemental Insurance Form
- Beneficiary Change Form - Life Insurance
- Worker's Compensation-1st Report of Injury
Submit this form to Risk Management, One Bear Place #97371, Waco, TX 76798-7371, Phone: (254)-710-7211
Accidental Death & Dismemberment (AD&D)
Cancer & Other Specified Diseases with Humana
Supplemental Term Life
- Application Form
- Evidence of Insurability Form
Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits.
Long Term Care
- Application
- Evidence of Insurability
Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits. - Acknowlegement of Disclosure Rating Practices
REQUIRED to be returned to insurer.
GuideStone, SBC
- Forms
- Vendor Designation Form
- Salary Reduction Agreement
- Salary Reduction Agreement - Roth
- 457(b) Salary Deferral Agreement
- 457(b) Benefit Payment Application
Vanguard
- Enrollment/Change Form
- Rollover Form
- Vendor Designation Form
- Asset Transfer Form
- Distribution Request Form
- In Service Withdrawal Form
- Salary Reduction Agreement
- Salary Reduction Agreement - Roth
- Vanguard MoneyWhys
TIAA-CREF
- Enrollment Form - BURIP
- Vendor Designation Form
- Enrollment Form - Supplemental
- Salary Reduction Agreement
- Salary Reduction Agreement - Roth
- To request distribution forms (withdrawal of funds, direct rollover) or change of beneficiary, contact TIAA-CREF's National Counseling Center at 800.842.2776. A TIAA-CREF representative will assist you in completing the appropriate form(s). Please provide Human Resources with the completed form(s).
Tuition Benefits
