Forms for Current Employees

Insurance

Initial Benefits Enrollment for New Employees

• My UT Benefits online enrollment system

  Review New Employee Benefits Enrollment Checklist for more information

Change in Status Event

• Insurance Enrollment / Change Application (PDF)
• Dependent Information (PDF)
• Proof of Relationship Cover Sheet (PDF)
• Dependent Grandchild Certification Form (PDF)
• Application for Term Life and Short/Long Term Disability (PDF)

Life and Accidental Death and Dismemberment (AD&D)

• Beneficiary Designation Form

Insurance Cost

• Benefits Cost Worksheet

Medical/Prescription

• UT SELECT Medical Claim Form
• Prescriptions by Mail Order Form
• Prescription Drug Reimbursement Form

UT FLEX

• Employee Health Care Reimbursement Claim Form
• Dependent Health Care Reimbursement Claim Form
• Letter of Medical Necessity
• UT Flex Benefits Guide

Retirement

• Pre-Retirement Checklist
• Annual Leave Deferral Purchase/Change Agreement (Online)
• Purchase / Change Agreement (All plans)
• Request a Certificate of Retirement (Online)
• Transfer Verification Form (All plans)
• UTSaver Tax-Sheltered Annuity (TSA) Disclosure Form

Time Off

• Employee Request for Family and Medical Leave (English, Spanish)
• FMLA Certification of Healthcare Provider Form – Employee (English, Spanish)
• FMLA Certification of Healthcare Provider Form – Family Member (English, Spanish)
• FMLA Certification for Qualifying Exigency Leave (PDF)
• FMLA Certification for Military Family Leave (PDF)
• Release to Return to Work (English, Spanish)
• Parental Time Off Form (English, Spanish)
• Request for Sick Leave Pool (English, Spanish)
• Sick Leave Pool Certification of Health Care Provider (English, Spanish)
• Leave of Absence Form (PDF)
• Sick Leave Donation to an Individual - Donor (English, Spanish)
• Sick Leave Donation to an Individual – Recipient (English, Spanish)

Compliance

• Annual Request For Outside Employment (Faculty/Exempt Staff)
• Annual Request For Outside Employment (Staff) (PDF)
• Health Insurance Marketplace Notice (PDF)
• Self Report of Current or Prior TRS participation
• Transfer of State Service Request (PDF)

Appointments at EAP (Employee Assistance Program)

• EAP Confidentiality and Consent Information (PDF)
• EAP Notice of Privacy Practices (PDF)
• EAP Client Information (PDF)
• EAP Non-Employee Client Information (PDF)
• EAP Manager Information (PDF)

Fitness for Duty

• Notification of Fitness for Duty Evaluation Procedure (PDF)
• Certification of Fitness for Duty (PDF)

Workers' Compensation

• First Report of Incident-Injury Memorandum (English, Spanish)
• Network Acknowledgement Form (English, Spanish)
• Notice of Network Requirements (English, Spanish)
• Request for Paid Leave

Other

• FERPA Authorization to Release Student Employment Records (PDF)
• New Employee Checklist
• Performance Appraisal (PDF)
• Performance Appraisal (DOC)
• Employee Self-Appraisal Form (PDF)
• Employee Self-Appraisal Form (DOC)
• Personal Information Update (PDF)
• President's Exemplary Service Award Nomination Form (PDF)
• Staff Emergency Fund Application (PDF)
• Time Report for Monthly Employees (PDF)
• Time Report for Hourly Employees (PDF)
• Volunteer Forms (PDF)