UTSaver TSA 403(b)/ UTSaver DCP 457/ Optional Retirement Program (ORP)
Forms
Enroll/ Change/ Cancel (www.vrsco.com)
Purchase/Change/Cancellation Agreement Form
Transfer Verification Form
Prescription Forms
HMO
Blue Form (90 Day Prescription Mail Order)
Medco Health
Form (90 Day Prescription Mail Order)
Medco Health Prescription Claim Form
UTMB Forms
Savings Bond Cancellation Form
Application for Sick Leave Pool Withdrawal
Zip Code
Exception Form
Claim Forms
How To File A Long-Term
Disability Claim
The Hartford Long-Term Disability
Delta Dental
Blue Cross Blue
Shield
Evidence of Insurability Forms
The Hartford STD & LTD
Fort Dearborn Life Insurance Form
UT Select PPO Form
Beneficiary Designation Forms
Ft. Dearborn Life
UT Flex Forms
PayFlex FY2005
UT Flex Enrollment Form
UT Flex Letter of Medical Necessity
UT Flex Direct Deposit Authorization Form
UT Flex Reimbursement Claim Form
Cobra Election Flex Form
Family Status Change
Family Status Change
Questions or
comments? Contact the Benefits Service Center at ext. 22630 or via email.
(Phone lines may be busy; we apologize for the inconvenience and thank
you for your patience.)
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