Forms & Publications

Forms & Publications

Need a form? We've listed our most popular forms here for your convenience, but be sure to review the plan detail pages (available at left) for additional information you might need before you download and return a form.

Life Changes

Have you had a recent change in your life that might affect your benefits? Find the information and forms you need on these pages:

Summary Annual Reports

Looking for summary annual reports?

Frequently Downloaded Forms & Publications

Find some of our most popular forms below, or you can view the full list of all our forms and publications.

Forms & Publications

Dental Plan Forms

TitleType
2018 Health/Dental/Vision Plan Enrollment/Change Formpdf
Health/Dental/Vision Plan Enrollment/Change Formpdf

Health Plan Forms

TitleType
2018 Health/Dental/Vision Plan Enrollment/Change Formpdf
Health/Dental/Vision Plan Enrollment/Change Formpdf
Health Plan Enrollment/Change Form for Retirees Under 65pdf
Notice of Continuation of Health/Dental/Vision Enrollment - for Postdoctoral Fellowspdf

Vision Plan Forms

TitleType
Vision Care Form 5500pdf
2018 Health/Dental/Vision Plan Enrollment/Change Formpdf
Health/Dental/Vision Plan Enrollment/Change Formpdf
EyeMed Out of Network Claim Formpdf
EyeMed Provider Nomination Formpdf

Pension Plan Forms

TitleType
Pension Plan Beneficiary Designation and Direct Deposit Forms (PensionConnect)html

401(k) Forms

TitleType
401(k) Plan Beneficiary Designation and Rollover Formshtml
Internal Revenue Service (IRS) Tax Saver's Credit Informationhtml
Internal Revenue Service (IRS) Tax Form 8880html

Preparing to Retire

TitleType
Pension Plan Beneficiary Designation and Direct Deposit Forms (PensionConnect)html
401(k) Plan Beneficiary Designation and Rollover Formshtml
401(k) Plan Distribution Options Brochurepdf
Active Employee Change of Address (ATLAS)html
Retiree/Former Staff Change of Addresshtml
Social Security Retirement Benefit Applicationhtml

Retirees 65 and Over

TitleType
Managed Blue for Seniors Description of Benefitspdf
Managed Blue for Seniors Summary of Benefitspdf
Medex Description of Benefitspdf
Medex Summary of Benefitspdf
Tufts Medicare Preferred Description of Benefitspdf
Tufts Medicare Preferred Summary of Benefitspdf
Tufts Medicare Complement Summary of Benefitspdf

Retirees Under 65

TitleType
Health Plan Enrollment/Change Form for Retirees Under 65pdf
Blue Care Elect PPO Summary of Benefitspdf
Blue Care Elect PPO Description of Benefitspdf
Blue Care Elect PPO Preventive Carepdf

Retiree Dental Plan Forms

TitleType
Retiree Dental Plan Enrollment Formpdf
Payment Form & Automatic Withdrawal Authorizationpdf

Life Insurance Forms

TitleType
Supplemental Life Insurance Enrollment/Change Formpdf
Life Insurance Beneficiary Designation Formpdf
Statement of Healthpdf

Health Care FSA Forms

TitleType
Flexible Spending Account Form 5500pdf
FSA Enrollment/Change Formpdf
Health Care FSA Reimbursement Formpdf
Health Care FSA Ineligible Item Repayment Formpdf
Letter of Medical Necessitypdf

Dependent Care FSA Forms

TitleType
Dependent Care FSA Reimbursement Formpdf
FSA Enrollment/Change Formpdf

Tuition Assistance Forms & Publications

TitleType
Career Development Proposal Formhtml
Tuition Assistance Summary Plan Descriptionpdf
Tuition Assistance Request Form
Use this form only if you are unable to access your Tuition Assistance Account in Atlas.
pdf
Sample Student Account Statement Suitable for Reimbursementpdf

Domestic Partnership

TitleType
Affidavit of Domestic Partnershippdf
Declaration of Termination of Domestic Partnershippdf
2017 Domestic Partner Health Coverage Taxable Income & Costspdf