Benefit Forms and Documents 

   
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.
 
 

Benefit Forms and Documents  

Benefits Guide and Rates 
Benefits Election/Change Summary Forms 
Medical Insurance 
Vision Insurance  
Dental Insurance  
Life Insurance  
Legal Shield (Pre-Paid Legal Service/IdentityTheft Shield Plan)  
Flexible Spending Account - Health Care and Dependent Care Plan   
Retirement Plan    
Summary Annual Report   

 


Benefits Guide and Rates

2015 Benefits Information

  • Welcome to Benefits Open Enrollment Memo
  • 2015 Benefits Open Enrollment Newsletter (highlights changes for 2015)
  • 2015 Benefits Guide (includes benefit plans and rate information)
  • Open Enrollment Instructions

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Benefits Election/Change Summary Forms

2014 

 

 2015 

  • 2015 Benefits Election/Change Summary (Form #3075) (Word version)
  • 2015 Benefits Election/Change Summary (Form #3075) (Adobe version)

Affidavit of Domestic Partner Benefits (Form #3032)  

 

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Medical Insurance 

Enrollment Application

NOTE: HAP HMO Enrollment Application must include HAP HMO Personal Care Physician's Name and PCPIN information available on the HAP web site at www.hap.org.

The Summary of Benefits and Coverage documents below show what the medical plans cover and what they cost.

AHL PPO Plan Information:

HAP HMO Plan Information:

HAP/AHL Pharmacy Mail Order Information

For additional information about the plans, link to HAP, PPO FAQs and HMO FAQs.

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Vision Insurance

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Dental Insurance

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Life Insurance 

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Legal Shield (Pre-Paid Legal Service/Identity Theft Shield)

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Flexible Spending Account (FSA)

NOTE: Indicate your 2015 FSA Health Care and/or Dependent Care election(s) on the 2015 Benefits Election/Change Summary Form #3075 (above)

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Retirement Plan

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Summary Annual Reports

 

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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.