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Category: Benefit Forms

URS 401k Withdrawal/Rollover Form

Complete this form to either rollover funds from a previous employer or to withdraw funds from your URS 401(k) account if you are leaving state employment.  2015 URS 401(k) Withdrawal/Rollover Form

Post (After) Retirement Employment Form

Complete this form when you are rehired retiree to acknowledge you have read the Explanation of Post Retirement Employment Restrictions and understand.  2015 Post (After) Retirement Employment Form

Short Term Disability Enrollment/Change Form

Enrollment and changes to short term disability must be completed online only here Please DO NOT USE the following form unless no computer access is available Short Term Disability Enrollment and Change Form  

Life Insurance Enrollment and Change Forms

All benefits eligible employees must complete these forms to designate beneficiaries for the basic coverage funded by the state.  You may also apply for additional coverage using the enrollment form.  Online enrollment and beneficiary designation can also be completed online using your myPEHP online account. Life Insurance Enrollment Form Disclosure Form Group Term Life Change Form

Life Insurance Enrollment Form for Spouse/Dependents

To enroll your spouse and/or dependents in the Life Insurance Plan PEHP offers complete this form and submit to PEHP directly.  This enrollment may also be completed using the online PEHP enrollment option available on myPEHP. Life Insurance Spouse Dependent Enrollment Form

Life Insurance Enrollment and Change Forms for EXEMPT Employees

If you are CAREER SERVICE EXEMPT, you may be eligible to enroll in Exempt Life Insurance (state-paid). See below for the applicable enrollment, disclosure and change forms. Information about life insurance for CAREER SERVICE employees, can be found here. For questions, please contact the Employee Resource Information Center (ERIC) at 801-538-3742. State-Exempt Group Term Life Enrollment Form Disclosure Form Group Term Life Change Form

Flexible Spending Account (FSA) Claim Form

Complete this form to submit eligible expenses for reimbursement from your Flexible Spending Account (FSA).  This form and any receipts or documentation must be sent directly to PEHP by mail to the address listed on the form or via fax to 801-366-7772 Flex Claim Form

Accidental Death & Dismemberment Form

Complete this form to enroll in or make changes to the Accidental Death & Dismemberment optional plan offered by PEHP. Accidental Death & Dismemberment Enrollment/Change Form

Flexible Spending Account (FSA) Enrollment Form

Complete this form to enroll in a Flexible Reimbursement Account. Flex Enrollment Form OR Online Flex Enrollment (Once logged in to your myPEHP account, select Online Enrollment)

URS Investment Contract for 401k or 457 Plan

Complete this form to make changes to your 401k or 457 plan or to notify Utah Retirement systems you no longer want to contribute.  Any questions related to this form can be directed to an HR Representative at the Employee Resource Information Center by calling 801.538.3742. 2015 URS Investment Contract for 401(k) or 457 Plan

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