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HRM Forms - Benefits

 

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Benefit Forms by Name (in alphabetical order)Instructions or Information about form
Accidental Death & Dismemberment (AD&D) Claim FormAccidental Death & Dismemberment (AD&D)
Accidental Death & Dismemberment (AD&D) Conversion FormAccidental Death & Dismemberment (AD&D)
Accidental Death & Dismemberment (AD&D) Enrollment/Change FormMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Adding Dependent/Spouse to Insurance Plan(s)Benefits
Address ChangeChanging/Updating address with LSU and insurance providers.
Aetna Nomination FormLSU First will reach out to a physician to join if they are not part of the Aetna network.
Authorization Agreement for ACH Insurance Deductions (Retirees only)Retirees
Blue Cross Blue Shield Claim Form  for HMO & PPOHealth Insurance: Blue Cross Blue Shield
Blue Cross Blue Shield (Catamaran ) Prescription Claim Form Health Insurance: Blue Cross Blue Shield
Boon Chapman Dependent Care Claim FormFlexible Spending & Dependent Care Spending Accounts
Boon Chapman Dependent Care Spending Account Enrollment FormMust enroll within first 30 days of employment or during Annual Enrollment.
Boon Chapman Flexible Spending Account Direct Deposit FormFlexible Spending & Dependent Care Spending Accounts
Boon Chapman Flexible Spending Account Enrollment FormMust enroll within first 30 days of employment or during Annual Enrollment.
Boon Chapman Flexible Spending Account Expense Estimation Worksheet for Unreimbursed Healthcare CostsFlexible Spending & Dependent Care Spending Accounts
Boon Chapman Flexible Spending Account - Healthcare Claim FormFlexible Spending & Dependent Care Spending Accounts
Change of AddressChanging/Updating address with LSU and insurance providers.
Change NameChanging/Updating name with LSU and insurance providers.
Continuation of Benefits for Employees on LWOP - G1-1Use if continuing benefits while on Leave Without Pay.
Davis Vision Enrollment/Change FormMust enroll within first 30 days of employment or during Annual Enrollment.
Davis Vision Claim FormVision Insurance
Dearborn National Enrollment Form (Dental)Must enroll within first 30 days of employment or during Annual Enrollment.
Dearborn National Claim Form (Dental)Dental Insurance
Dearborn National Nomination FormDental Insurance
Dependent Care Spending Account Claim FormFlexible Spending & Dependent Care Spending Accounts
Dependent Care Spending Account Enrollment FormMust enroll within first 30 days of employment or during Annual Enrollment.
Dental Enrollment/Change FormMust enroll within first 30 days of employment or during Annual Enrollment.
Dental Claim FormDental Insurance
Express Scripts (LSU First) Prescription Claim FormHealth Insurance: LSU First
Flexible Spending Account Continuation/Cancellation Form         (for LWOP) - G1-1 FlexUse if continuing/canceling flex benefits while on Leave Without Pay.
Flexible Spending Account Direct Deposit FormFlexible Spending & Dependent Care Spending Accounts
Flexible Spending Account Enrollment FormMust enroll within first 30 days of employment or during Annual Enrollment.
Flexible Spending Account Expense Estimation Worksheet for Unreimbursed Healthcare CostsFlexible Spending & Dependent Care Spending Accounts
Flexible Spending Account Claim Form (Healthcare)Flexible Spending & Dependent Care Spending Accounts
HIPAA Form 
HMO Claim FormHealth Insurance: Blue Cross Blue Shield HMO
HMO Enrollment FormMust enroll within first 30 days of employment or as a late applicant.
HMO Prescription Claim FormHealth Insurance: Blue Cross Blue Shield HMO
Health Insurance Enrollment/Change FormMust enroll within first 30 days of employment or as a late applicant.
LSU First Claim FormHealth Insurance: LSU First
LSU First Critical Illness Direct Cash Benefit FormHealth Insurance: LSU First
LSU First Enrollment FormMust enroll within first 30 days of employment or as a late applicant.
LSU First Medical Claim FormHealth Insurance: LSU First
LSU First Prescription Claim Form (Express Scripts)Health Insurance: LSU First
Life Insurance - LSU System/The Hartford  
Life Insurance Beneficiary Designation/Change Form - The HartfordLife Insurance
Life Insurance Cancellation Form - The HartfordLife Insurance
Life Insurance Claim Form - The HartfordLife Insurance
Life Insurance Conversion Form - The HartfordLife Insurance
Life Insurance Enrollment Form - The HartfordMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Life Insurance Evidence of Insurability Form - The HartfordLife Insurance
Life Insurance Name/Address Change Form - The HartfordLife Insurance
Life Insurance Portability Application Form - The HartfordLife Insurance
Life Insurance - Prudential  
Life Insurance Beneficiary Designation/Change Form- PrudentialLife Insurance
Life Insurance Cancellation Form - PrudentialLife Insurance
Life Insurance Conversion Form - PrudentialLife Insurance
Life Insurance Enrollment Form- PrudentialMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Life Insurance Evidence of Insurability Form- PrudentialLife Insurance
Life Insurance Health Statement Questionnaire- PrudentialLife Insurance
Life Insurance Name/Address Change Form- PrudentialLife Insurance
Life Insurance Portability Application Form- PrudentialLife Insurance
 
Long Term Care Cancellation FormLong Term Care
Long Term Care Enrollment FormMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Long Term Care Evidence of Insurability ApplicationLong Term Care
Long Term Care Portability FormLong Term Care
Long Term Disability Conversion FormLong Term Disability
Long Term Disability Claim FormLong Term Disability
Long Term Disability Enrollment/Change FormMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Long Term Disability Evidence of Insurability ApplicationLong Term Disability
Louisiana Deferred Compensation Address, Name, Information Change FormDCCL Retirement
Louisiana Deferred Compensation Beneficiary Designation/Change FormDCCL Retirement
Louisiana Deferred Compensation Enrollment FormDCCL Retirement
Louisiana Deferred Compensation Salary Deferral AgreementDCCL Retirement
Name ChangeHow to change name with LSU and insurance providers.
Office of Group Benefits - Enrollment/Change FormBenefits
PPO Claim FormHealth Insurance: Blue Cross Blue Shield PPO
PPO Enrollment FormMust enroll within first 30 days of employment or as a late applicant.
PPO Prescription Claim FormHealth Insurance: Blue Cross Blue Shield PPO
Premiums Only Plan Enrollment/Change FormMust enroll within first 30 days of employment or during Annual Enrollment.
Retirement Forms 
Status Change FormBenefits
Unum Long Term Care Enrollment FormMust enroll within first 30 days of employment or as a late applicant and be medically underwritten.
Unum Long Term Care Evidence of Insurability ApplicationLong Term Care
Unum Long Term Care Cancellation FormLong Term Care
Unum Long Term Care Portability FormLong Term Care
Vantage Claim FormHealth Insurance
Vision Enrollment/Change FormMust enroll within first 30 days of employment or during Annual Enrollment.
Vision Claim FormVision Insurance
Voluntary Benefits Enrollment/Change FormSupplemental Benefits

 

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Form directions and/or additional information are provided in the Instructions or Information column or within the form.

 

Forms that are submitted HRM can be scanned and emailed (unless original documents are required for processing) to hr@lsu.edu or sent via campus mail to 110 Thomas Boyd Hall.

 

For technical support on forms, contact an HR Generalist at 225-578-8200 or hr@lsu.edu.