Forms: Short Term Disability

Below are the forms for the Short Term Disability plan.

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.
STD Claim Form ( PDF)	Short 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.