Benefit Plan Forms and Documents

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Benefits Enrollment or Change

Important: Be sure to review your beneficiary designations for life insurance and your retirement savings accounts and make updates as necessary whenever you experience a life event that changes your eligible dependents, or when there is a change affecting the people you have listed as your beneficiary. For example, the death of a loved one, a marriage or divorce, or the birth or adoption of a child are life events that may necessitate changing your beneficiary so that your financial wishes will be met.

Please Note: When completing benefits-related information, the definition for "Gender" is the dependent's gender at birth. This information is used to ensure accurate claims processing.

View Current Benefits

View a summary of your current benefits by navigating to the Wolverine Access "Employee Self-Service" menu. 

After you click on "Employee Self Service," you'll be directed to the Duo Mobile identification app on your cellphone. Click the green checkmark, then go back to Wolverine Access and click "Benefits" and "Benefits Summary." 

COBRA

These resources pertain to COBRA continuation of your benefits.

Dental Plan

Enrollment in the Dental Plan is completed through Wolverine Access.

Use the Delta Dental Claim Form if you receive services from a non-participating dentist

Dependent Information

Dependent Information Form 

This form is for information only and does not enroll your dependents in benefits. Use this form to update information for your eligible dependents with the University of Michigan.

Please Note: When completing benefits-related information, the definition for "Gender" is the dependent's gender at birth. This information is used to ensure accurate claims processing.

The Affordable Care Act requires large employers like the university to report Social Security numbers for individuals and their covered dependents on Form 1095, a new tax form that reports information about health coverage. If you received a notice from the university because a Social Security number is not on file for one or more dependents covered by your University of Michigan health plan, please complete the Dependent Information Form and return it as instructed on the form. IMPORTANT INFORMATION: Under the Affordable Care Act, health coverage is not affected and will not be canceled if you do not provide a covered dependent's Social Security number. If not provided after multiple requests, the university will report to the IRS using your dependent's date of birth.

Application for Principally Supported Child

Disabled Dependent Certification

Expanded Long-Term Disability

Access Long-Term Disability Forms and Documents. 

Flexible Spending Accounts

Access Flexible Spending Account Forms and Documents. 

Graduate Students

These forms are for use by graduate students enrolled in GradCare.

Please Note: When completing benefits-related information, the definition for "Gender" is the dependent's gender at birth.  This information is used to ensure accurate claims processing.

Benefits Enrollment Change Form for Benefit-Eligible Fellowship or Medical Students

GradCare Off-Site Registration Form (required for Level 2 care) 
The department administrators can email the completed form to BCN at [email protected], however, they should be aware that the form must include the specific program date span (begin date mm/dd/yyyy, end date mm/dd/yyyy) and the department head signature. If the department head is unable to sign, the department administrator should include in the body of the email that the form is "an approved off-site registration for (name and ID)." 

Health Plans

Access Health Plan Forms and Documents. 

Health Plan Claim Forms

Use these forms to submit a claim to your health plan if you receive out-of-network services.

  1. Go to the Blue Cross Blue Shield Global website.
  2. Click to accept the terms and conditions.
  3. Enter the three letters of your "Enrollee ID" found on your Blue Cross Blue Shield member ID card, and then click Go.
  4. Select Claims on the menu bar.
  5. To file a Blue Cross Blue Shield Global Core eClaim online, log in with your username and password or register for access.​​

Health Plan Documents

Enrollment in the Legal Services Plan is completed through Wolverine Access. 

Legal Services Plan Book

Life Insurance

Life Insurance Forms and Documents 

Enrollment in the University Life Insurance Plan is automatic for newly eligible faculty and staff hired after 1/1/2016, and does not require any forms. You must be enrolled in the University Life Insurance Plan in order to enroll in the Optional Plan or Dependent Life. Forms are available to enroll in additional coverage, to change or cancel your coverage, or to designate beneficiaries.

Health Statement

A health statement provides proof of insurability and may be required under certain circumstances. If your application for Life Insurance coverage requires completion of a Statement of Health (SOH) form, you will receive an email from MetLife with instructions on how to complete the statement of health.

Learn more about the MetLife Health Statement

MetLife Privacy Notice

Other Qualified Adult

The university will assume your OQA and/or your OQA's child(ren)DO NOT qualify as your tax dependent for tax-free university sponsored group health insurance unless a Declaration of Tax Status Form is completed at the start of each tax year and is on file with the Benefits Office. Interactive Imputed Income Worksheet You or your OQA must submit a Notice of Qualifying Event form to report a loss of eligibility within 60 days of the qualifying event and COBRA continuation information will be sent to your OQA. 

Prescription Drug Plan

There are no forms to enroll in the U-M Prescription Drug Plan. Enrollment is automatic for you and all eligible dependents covered under your U-M Health Plan.

Prescription Drug Plan Claim Form

Prescription Drug Plan Documents

Retirees

Agreement for Preauthorized Benefit Premium Payments

Your Retirement Benefits

Retirement Savings Plans

Retirement Savings Plan Forms

Most retirement savings plan elections are completed in Wolverine Access.  

Temporary Employees

Use the form below if you are a temporary employee and wish to enroll in an SRA.

Compulsory Participants

If you are a compulsory participant in the Basic Retirement Plan (you are age 35 or older, with two or more years of eligible service, and you have a 100% appointment effort), and you would like to cancel the Reduced Benefit Option, you may elect to contribute 5% and receive the 10% U-M match. Download and complete the eForm. If you prefer a paper version, download the Cancel the Reduced Benefit Option form and return it as instructed on the form to enact the change in contribution rates.

Retirement Savings Plan Guides and Checklists

These resources provide answers to common questions about the U-M retirement savings plans at a glance.

Retirement Savings Plan Books

These books provide an overview of the U-M retirement savings plans and information about continuing benefits when you retire from U-M.

Vision Plan

Vision plan benefits are provided by Davis Vision by MetLife.