Forms: Long Term Disability

Below are forms for the Long Term Disability plan. For the forms pertaining to more than one benefit plan, please refer to the Human Resources Benefits Forms Page

Newly eligible faculty & staff may conviently elect to or waive healthcare coverage using the eBenefits, HRIS Self Service module.
Evidence of Good Health Application ( PDF)	Use this form to provide documentation of good health. Claims submitted for a condition, including pregnancy, disclosed on the application will not be covered for at least one year from the coverage effective date.
Leave of Absence Application ( PDF)	Staff Leave of Absence Provisions and Application Forms.
LTD Claim Form ( PDF)	Long Term Disability Claim Form.
Benefit Enrollment and Change ( PDF)	After hire, use this form to enroll in the health plan or change the coverage of a spouse or dependent child as a result of a change in family or employment status. Must be submitted within 31 days from the date of the qualifying event.
Newly eligible faculty & staff may conviently elect to or waive healthcare coverage using the eBenefits, HRIS Self Service module.