EMPLOYEE BENEFITS

Forms & Publications

Find commonly used Employee Benefits forms and publications below. Most forms are in PDF format. Some require an MIT certificate (get help with certificates).

• 2009 Open Enrollment Newsletter (pdf)
• 401(k) Investment Options Guide (pdf)
• 401(k) Plan Beneficiary Designation Form (pdf)
• 401(k) Plan Rollover Form (pdf)
• 401(k) Summary Plan Description (pdf)
• Affidavit of Spousal Equivalent Partnership (pdf)
• Basic Retirement Plan Beneficiary Designation Form (pdf)
• Basic Retirement Plan Direct Deposit Form (pdf)
• Basic Retirement Summary Plan Description (pdf)
• Change Pension Deposit Form (pdf)
• Change of Address Form * (Active Employees ONLY)
• Change of Address Form (Retirees and Former Staff ONLY)
• Children's Scholarship Plan Booklet (pdf)
• Children's Scholarship Plan Application (pdf)
• Delta Dental Coverage Chart (MIT Basic Dental Plan) (pdf)
• Delta Dental Coverage Chart (MIT Comprehensive Dental Plan) (pdf)
• Delta Dental Enrollment Form (pdf)
• Educational Loan Plan Application (pdf)
• Election of Lump Sum Benefit Form (pdf)
• EyeMed Plan Details (pdf)
• EyeMed Out of Network Claim Form (pdf)
• EyeMed Provider Nomination Form (pdf)
• Fidelity Blue Chip Growth Fund (pdf)
• Fidelity Bond Oriented Balanced Fund (pdf)
• Fidelity Bond Pool (pdf)
• Fidelity Diversified International Fund (pdf)
• Fidelity Diversified Stock Fund (pdf)
• Fidelity Equity-Income II Fund (pdf)
• Fidelity Fund (pdf)
• Fidelity Retirement Money Market Portfolio (pdf)
• Fidelity's Spartan Extended Market Index Fund (pdf)
• Fidelity U.S. Equity-Index Commingled Pool (pdf)
• Flexible Spending Account Enrollment / Change Form (pdf)
• Flexible Spending Account Health Care Claim Form (pdf)
• Flexible Spending Account Dependent Care Claim Form (pdf)
• Formulary List (pdf)
• Health Care Comparison Chart (pdf)
• Health Plan Change Form (pdf)
• Health Plan Enrollment Form (pdf)
• Health Plan Form for Retirees (pdf)
• Investment Options Overview (pdf)
• Leave of Absence Request Forms
• Life Insurance Beneficiary Designation Form (pdf)
• Life Insurance Enrollment/Change Form (pdf)
• Medicare Supplement Plan Comparison Chart (pdf)
  (Please note: Secure Horizons is now Tufts Health Plan Medicare Preferred)
• Notice of Privacy Practices for M.I.T. Self-Funded Employee Health Benefits (pdf)
• Notice of Continuation of Health Enrollment for Postdoctoral Fellows(pdf)
• Publication 502 (2008) Health Coverage Tax Credit
• Reasonable Accommodation Request Form (pdf)
• Spousal Equivalent Partnership Affidavit (pdf)
• Tuition Assistance Request Form (pdf)
• Workers Compensation Injury Report Form *

* MIT Certificate Required