Benefit Forms and Documents
Enrollment Instructions
New Employee or New Benefit Eligible Employee
All new employees must complete the Benefits Election/Change Summary Form #3075 and applicable benefit enrollment form(s) listed below. All benefit forms must be received by the Office of Human Resources within 30 days of eligibility. Failure to submit elections within the 30-day deadline will result in no insurance coverage for the entire plan year.
Benefits Open Enrollment
During the 2012 Benefits Open Enrollment period, October 24 - November 4, 2011, current employees may switch, add, adjust or cancel insurance and/or add or remove spouse or dependent(s) from coverage. Employees who do not initiate a change during open enrollment will automatically continue in their current benefit coverage for 2012, except for Flexible Spending Account (FSA) plans. Employees must re-enroll in the FSA plan annually. Access the benefits Enrollment Instructions for full details. All benefit enrollment/change forms must be submitted to the Office of Human Resources by November 4, 2011.
Special Enrollment Period
If you have a qualifying "status change" event during the year, you may be allowed to make changes to your benefits mid-year. Link to life events - special enrollment period for additional information regarding qualifying status change events. All benefit enrollment/change forms must be received by the Office of Human Resources within 30 days of the event.
Benefit Forms and Documents 
Benefits Newsletter and Guide
Benefits Election/Change Summary
Medical Insurance
Vision Insurance
Dental Insurance
Life Insurance
Pre-Paid Legal Service/IdentityTheft Shield Plan
Flexible Spending Account - Health and Dependent Plan
Waiver of Insurance
Retirement Plan
Summary Annual Report
Benefits Newsletter and Guide
- Welcome to Benefits Open Enrollment
- 2012 Benefits Open Enrollment Newsletter
- 2012 Benefit Guide
- 2012 Monthly Health Insurance Rates
Benefits Election/Change Summary
- Benefits Election/Change Summary (Form #3075)
- Certification of Other Medical Insurance (Form #3122)
- Affidavit of Domestic Partner Benefits (Form #3032)
Medical Insurance
- Alliance Health and Life Employee Enrollment Application (Form #3083)
- Alliance Health and Life Membership and Record Change (Form #3082)
- iStrive Instructions
- Blue Care Network Enrollment/Change of Status (Form #3599)
Vision Insurance
Dental Insurance
Life Insurance
- The Standard Life and Long Term Disability Insurance Enrollment and Change (Form #7533)
- The Standard Life Insurance Medical History Statement (Form #9347)
- The Standard Life Termination/Reduction (Form #1797)
Pre-Paid Legal Service and/or Identity Theft Shield (PPLS/ITS)
Flexible Spending Account (FSA)
- 2012 FSA - Health Care or Dependent Care Election (Form #3013)
- WageWorks Health Care Claim Form
- WageWorks Dependent Care Claim Form
Waiver of Insurance
Retirement Account
Summary Annual Reports
Questions? Email benefits@ltu.edu.
Limitations
Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Office of Human Resources reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.
Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Office of Human Resources reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.