Benefit Forms
HEALTH CARE(Please complete your benefit elections online via your MyUT portal):
Health Savings Account (HSA) Employee Election/Contribution Form
Health Savings Account (HSA) Employer Authorization Form
Flexible Spending Account Election Form
Flexible Spending Account Direct Deposit Form
Flexible Spending Claim Reimbursement Form
Prescription Reimbursement Form
TUITION WAIVER:
Tuition Waiver Form- To be used for employee out of state tuition (undergraduate and graduate), dependent out of state tuition (undergraduate), and all dependents of retirees.
Dependent Fee Waiver Certification-If you do not currently cover your child under any UToledo health benefit plan, please submit this completed form along with a copy of their birth certificate to benefits@utoledo.edu.
LIFE INSURANCE: