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Forms & Info

These forms are PDF files. You will need Adobe Acrobat installed on your computer. If you don’t see the form you need, contact your HR office or UBT’s Customer Service at (614) 508-2255 or (800) 228-5088 or email customerservice@benefitstrust.org for further assistance.

Plan Booklets

2018 Open Enrollment Guide

Download


This booklet is your guide for dental, vision, life insurance and the legal plan.

New Hire Guide

Download


This booklet covers supplemental life and the legal service plan, benefits available to you within 90 days of hire.

One Year Anniversary Guide

Download


This booklet covers dental, vision and basic life insurance, benefits available to you with at least one year of state service.

Legal Plan Booklet

Download


This booklet covers the legal service plan, once you are enrolled.

2017 Open Enrollment Guide

Download


This booklet is your guide for dental, vision, life insurance and the legal plan.

 

Enrollment Forms

Dental/Vision Enrollment and Change Form

Download


Use this form to enroll in or change the dental and vision plans.

2018 Legal Plan Enrollment Form

Download


Use this form to enroll in the legal service plan. This is also the form to use when changing or dropping your legal plan coverage, which you may only do during open enrollment.

Supplemental Life Enrollment Form

Download


Use this form to enroll in or change your supplemental life insurance coverage for you and your dependents. You can enroll in supplemental life insurance within 90 days of hire or during any open enrollment.

 

Life Insurance Forms

Group Life Insurance Continuation for Laid Off Members

Download


Beneficiary Form

Download


Use this form to designate a beneficiary for your basic and/or supplemental life insurance. A designated beneficiary on file will ensure that your benefits go directly to those you care about, should you die while covered under basic or supplemental life insurance.

 

 

Other Forms

Student Eligibility Affidavit

Download


Use this form when your dependent is age 19-23 and attending college.

Dental and Vision Appeal Form for Union Represented Employees

Download


Use this form when your or your dependents dental and vision coverage has been denied.

 

Information

Delta Dental Comparison Chart

Download


A comparison of the Delta Dental network reimbursement.

New! 2018 Wellness Benefits

Download


This page shows the Wellness Benefit.

Vision Plans Comparison Chart

Download


A comparison of the vision plans.

Supplemental Life Insurance Eligibility

Download


This page shows supplemental life eligibility.

Dependent Eligibility

Download


This page shows dental and vision dependent eligibility.

Basic Life Imputed Income

Download


2018 Open Enrollment Trust Chat

Download


2017 Open Enrollment Trust Chat

Download


 

Claim Forms

Dental Claim Form

Download


When using a non-network dentist, download, print and take this form with you.

VSP Out of Network Claim Form

Download


If you have VSP, and are using a non-network provider, download, print and take this form with you.

EyeMed Out of Network Claim Form

Download


If you have EyeMed, and are using a non-network provider, download, print and take this form with you.

Dental Claims Appeal Procedure

Download


Use this information to request a formal appeal of your denied dental claim.