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Category: Benefit Forms

Express Scripts COB Form

Complete this form to submit a claim to for pharmacy purchases. Express Scripts COB and Reimbursement Form

Express Scripts by Mail

Complete this form to submit a prescription by mail to Express Scripts to the address listed on the claim form. Express Scripts by Mail form

Savings Plans Direct Deposit for One-time Payments

Use this form for a direct deposit of one-time payments from your Utah Retirement Systems (URS) Savings Plans (401(k), 457, and IRAs). Completed forms can be sent directly to URS at fax number 801-366-7445. URS Savings Plans Direct Deposit for One-time Payments

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Military Leave Worksheet

This form is for employees who will be out on Military Leave (after 15 days of Military Leave has been exhausted).  The form allows the employee to select options for payment of premiums during military leave and designates how much personal leave the employee would like to use. Military Leave Form (Excel) Military Leave Form (PDF)

URS Statement of Ineligibility

This form notifies URS when an employee is not eligible for retirement benefits and also notifies the employee they can contribute on their own to a 401k account if they choose to do so.  This certification is normally part of the Onboarding process completed by the Employee Resource Information Center. URS Statement of Ineligibility 1/2014

URS Leave Notification Form

This form notifies URS when an employee is out on Leave Without Pay status so retirement benefits can be adjusted as necessary. URS Leave Notification

URS Eligibility Certification Form

This form notifies Utah Retirement Systems an employee is eligible for retirement benefits.  An authorized signature is required and this process is normally part of the Onboarding process of a new state employee. URS Eligiblity Certification Form

URS 457 Withdrawal/Rollover Form

Complete this form to rollover eligible funds to your URS 457 account or to withdraw funds upon leaving state employment. 2015 URS 457 Withdrawl/Rollover Form

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