Benefit Plan Forms and Documents


Benefits Enrollment or Change


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.

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.

Disabled Dependent Certification

Application for Principally Supported Child

Expanded Long-Term Disability

Use the Expanded Long-Term Disability Application with Health Statement when:
• More than 30 days have passed since your hire date or date of eligibility and you wish to enroll
• You have two or more years of service and wish to increase your coverage over the coverage that is paid for by the university

Expanded Long-Term Disability Forms

Expanded Long-Term Disability Documents

Flexible Spending Accounts

Flexible Spending Account Enrollment Forms

  • Open Enrollment - 2017 Flexible Spending Account Enrollment Form (for eligible faculty and staff) 
    If you want to participate in and FSA for 2017, you will need to re-enroll even if you currently have an FSA. IRS rules do not permit FSA enrollments to carry over from year to year. Enroll through Wolverine Access during Open Enrollment, October 24 to 5:00 p.m. on November 4, 2016. Or, submit your completed and signed form by December 4, 2016 to have funds available for reimbursement on January 1, 2017. If you submit your form by December 31, 2016, funds will be available February 1, 2017, and you will not be able to use your FSA debit card or file claims for 2017 expenses until after that date. (Dates refer to Health Care FSAs only.)

Flexible Spending Account Change Forms

Flexible Spending Account Documents

Graduate Students

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

GradCare Off-Site Registration Form

Benefits Enrollment Change Form (for benefit-eligible fellowship holders and medical students)

Health Plans

Health Plan Forms

Health Plan Claim Forms

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

Health Plan Documents

2016 Health Plan Coverage Comparison Chart

2017 Health Plan Coverage Comparison Chart

In Vitro Fertilization Benefit

2016 Summary of Benefits and Coverage

Use these documents for quick reference about your health plan coverage or to easily compare your health plan options.  

Uniform Glossary of Health Coverage and Medical Terms

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

2016 Legal Services Plan Book 

2017 Legal Services Plan Book

Life Insurance

Life Insurance Forms

Enrollment in the University Life Insurance Plan is automatic for newly eligible faculty and staff, 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

Life Insurance Documents

University Group Term Life Insurance Plans book for information on the University Life, Optional Life, and Dependent Life Insurance plans.

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 Forms

Prescription Drug Plan Documents


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.  Use the forms below if you are a temporary employee or if you need help reconciling your paychecks to your quarterly statements from TIAA or Fidelity.

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.