Job Aids & Forms - Benefits

 
Workday Job Aids
2017 Open Enrollment icon
Change Benefits * Benefits can only be changed during Annual Enrollment (October) or due to a qualifying event.
Manage (Add/Change) Beneficiaries
Manage (Add/Change) Dependents
Modify Personal Information (Address/Name)
Cancel Life Insurance 

 

Forms by Name (in alphabetical order) Instructions or Information about form
Accelerated Death Benefit Claim Form Life Insurance
Accident Protection Plan Beneficiary Form Accident Protection
Accident Protection Plan Claim Form Accident Protection
Aetna Nomination Form LSU First will reach out to a physician to join if they are not part of the Aetna network.
Authorization Agreement for ACH Insurance Deductions (Retirees only) Retirees 
Blue Cross Blue Shield Claim Form for Magnolia and Pelican Plans Health Insurance: Blue Cross Blue Shield 
Blue Cross Blue Shield (MedImpact) Prescription Claim Form Health Insurance: Blue Cross Blue Shield
Citizens Rx Mail Order Prescription Registration Form Submit this electronic form to enroll in mail order prescription delivery for 2016.
Continuation of Benefits for Employees on LWOP - G1-1 Use if continuing benefits while on Leave Without Pay. 
Critical Illness Protection Plan Claim Form Critical Illness Protection 
Dental Claim Form - UnitedHealthCare Dental Insurance 
Dental Provider Nomination Form - UnitedHealthCare Dental Insurance
Dependent Care Spending Account Claim Form Flexible Spending & Dependent Care Spending Accounts
Flexible Spending Account Continuation/Cancellation Form (for LWOP) - G1-1 Flex Use if continuing/canceling flex benefits while on Leave Without Pay. 
Flexible Spending Account Direct Deposit Form Flexible Spending & Dependent Care Spending Accounts 
Flexible Spending Account Expense Estimation Worksheet for Unriembursed Healthcare Costs Flexible Spending & Dependent Care Spending Accounts 
Flexible Spending Account Claim Form (Healthcare) Flexible Spending & Dependent Care Spending Accounts 
HIPAA Form  
Insurance Vesting Request Form Use for confirmation of medical insurance for vesting purposes. 
LSU First Claim Form Health Insurance: LSU First 

Life Insurance - UnitedHealthCare  

 
Life Insurance Claim Form - UHC  Life Insurance
Life Insurance Conversion Form - UHC  Life Insurance
Life Insurance Evidence of Insurability Form - UHC  Life Insurance
Life Insurance Portability Application Form - UHC  Life Insurance

Life Insurance - OGB State Group  

 
Life Insurance Conversion Form - OGB State Group  Life Insurance
Life Insurance Evidence of Insurability Form - OGB State Group  Life Insurance
Life Insurance Health Statement Questionnaire - OGB State Group  Life Insurance
Life Insurance Portability Application Form - OGB State Group Life Insurance
Long Term Care Cancellation Form  Long Term Care
Long Term Care Enrollment Form  Must enroll within first 30 days of employment or as a late applicant and be medically underwritten. 
Long Term Care Evidence of Insurability Application  Long Term Care
Long Term Care Portability Form Long Term Care 
Long Term Disability Claim Form  Long Term Disability
Long Term Disability Evidence of Insurability Application  Long Term Disability 
Long Term Disability Portability Form  Long Term Disability 
Magnolia Local Claim Form  Health Insurance: Blue Cross Blue Shield Magnolia Local 
Magnolia Local Prescription Claim Form Health Insurance: Blue Cross Blue Shield Magnolia Local 
Magnolia Local Plus Claim Form  Health Insurance: Blue Cross Blue Shield Magnolia Local Plus
Magnolia Local Plus Prescription Claim Form Health Insurance: Blue Cross Blue Shield Magnolia Local Plus
Magnolia Open Access Claim Form  Health Insurance: Blue Cross Blue Shield Magnolia Open Access
Magnolia Open Access Prescription Claim Form Health Insurance: Blue Cross Blue Shield Magnolia Open Access 
Pelican HRA 1000 Claim Form  Health Insurance: Blue Cross Blue Shield Pelican HRA 1000 
Pelican HRA 1000 Prescription Claim Form Health Insurance: Blue Cross Blue Shield Pelican HRA 1000 
Pelican HSA 775 Claim Form  Health Insurance: Blue Cross Blue Shield Pelican HSA 775 
HSA Enrollment Form Health Insurance: HSA 775
Pelican HSA 775 Prescription Claim Form Health Insurance: Blue Cross Blue Shield Pelican HSA 775 
Vantage Claim Form Health Insurance
Vision Claim Form Vision Insurance
Vision Provider Nomination Form Vision Insurance

 

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Form directions and/or additional information are provided in the Instructions or Information column or within the form.

Forms that are submitted HRM can be scanned and emailed (unless original documents are required for processing) to hr@lsu.edu or sent via campus mail to 110 Thomas Boyd Hall.

For assistance, please contact an HR Generalist at 225-578-8200 or hr@lsu.edu.

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