Print Form
THE UNIVERSITY OF TEXAS AT DALLAS Insurance Enrollment/Change Authorization Form
Section A: Employment Info Department Campus Ext
UTD-ID Name Male Female
Employment Type: Check one Full-time Employee Part-time Employee Retired Surviving Dep/Military Dep
If applicable, I am transferring from:
Section B: Declining Medical Coverage
1. I have non-group health insurance; but, I want UTD optional coverage. (Complete Section C & sign the form.)
2. I have other State funded medical coverage , i.e. TRS Care, but I want to elect & pay for UTD optional coverage.
(Complete Section C & sign the form.)
Section C: Insurance Enrollment. Mark the coverage level you desire
Medical Insurance (includes $10,000 employee group life and $10,000 employee group accidental death)
Medical Plan: Employee Only
UT Select PPO, BCBS Waive Medical Coverage.
Employee & Spouse If I am enrolled in a group health plan that is not provided by the State of
HRM use:
100/002 Employee & Child(ren) Texas, I can use Premium Sharing money toward other qualified
100/P02 Family coverage. I must provide proof of the other group coverage.
Dental Plan - 105 Dental Coverage - HRM 115 or 135 Vision Plan Vision Coverage - HRM 110/111/
Dental Select Employee Only Employee Only
Delta Dental Superior Vision
Employee & Spouse Employee & Spouse
Assurant Dental
Employee & Child(ren) Employee & Child(ren)
No coverage
No coverage Family Family
Accidental Death & Dismemberment Employee Options: - HRM 200/222/
No coverage Maximum 10x annualized salary Fixed amount of $
Accidental Death & Dismemberment Dependent Options - HRM 200/222/
No coverage Dependent maximum Fixed amount of $
Short Term Disability - HRM 610/ Long Term Disability - HRM 600/
No STD coverage I want STD coverage No LTD coverage I want LTD coverage
Group Life Insurance Employee Options: - HRM 700/
No coverage 1 x salary 2 x salary 3 x salary 4 x salary 5 x salary 6 x salary
Group Life Insurance Dependent Options - HRM 701/DEP
No coverage $10,000 ea dependent $25,000 spouse + $10,000 ea child $50,000 spouse + $10,000 ea child
Retiree Group Life Options - HRM 700/ No coverage $7,000 $10,000 $25,000 $50,000
For HRM Use:
Bene ____ AS ____ Rvw ____
Privacy Notice: With few exceptions, you are entitled to be informed about the information U. T. Dallas collects about you. Under Sections 552.021 and 552.023 of the
Texas Government Code, you are entitled to receive and review this information. Under Section 559.004 of the Texas Government Code, you are entitled to have U. T.
Dallas correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business
Procedures Memorandum 32. The information that U.T. Dallas collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et
seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
Employee Signature Date
revised 06/18/2008