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Benefits & Welfare
Forms for Insurance/Flex Plans

These are the most commonly used insurance forms that can be downloaded and printed, completed and brought, mailed, or faxed to the TWU Office of Human Resources (OHR) for processing--except forms replaced by an online enrollment/change process.  Please provide a phone number on forms mailed or dropped off in case we have questions about the form you submitted.  Call the OHR if you need help with forms.

1. Employee Insurance Multipurpose Form (NON-Summer Enrollment changes) & Summer Enrollment ERS OnLine Enrollment:  Form/process used to make eligible changes to your insurance coverage and is a paper form for new hires or changes outside of Summer Enrollment, or, during Summer Enrollment, is an enrollment process completely online (paperless) using ERS OnLine for Summer Enrollment changes.  You can only make coverage changes within 30 days of an eligible family status change or during Summer Enrollment.  Contact the TWU OHR if you need to request changes outside of Summer Enrollment.  Some changes always require evidence of insurability (EOI) before you can enroll.

2. Supplemental Information Form  Form used to name or change your Primary Care Physician (PCP).  You can change your PCP any time.  A faster way to change is to call your insurance provider directly.

3. Evidence of Insurability Application (EOI)  Form used to apply for desired coverage not elected during your 1^st 30 days of employment.  You can only apply for coverage during Summer Enrollment or within 30 days of a family status change.  Agency Name:  TWU, Agency Number: 0731.  Mail directly to the address on the form--not to TWU.

4. TexFlex Enrollment/Change Form  Form used outside of Summer Enrollment to sign up or make changes to the flex plan program, TexFlex.  You can only enroll in TexFlex in your first 30 days of employment, during Summer Enrollment, or if a you have an eligible family status change.

5. Disability Claim Form  Form used to file a claim for Long Term and/or Short Term Disability.  The form is to be completed by the employee, the employee’s physician and then submitted to the OHR for completion and submission.

6. Retiree Insurance Enrollment Form  Form used for employees who are retiring and are eligible for retiree insurance and want to continue health, dental, and/or life insurance into retirement.

7. Supplemental Information Form for Retirees  Form used for retirees under age 65 to name their Primary Care Physician (PCP). 

8. Additional ERS Forms

9. BCBS/HealthSelect Claim Forms

10. Medco Claim Forms