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
2023 Open Enrollment Guide
This booklet is your guide for dental, vision, life insurance and the legal plan.
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New Hire Guide
This booklet covers supplemental life and the legal service plan, benefits available to you within 90 days of hire.
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One Year Anniversary Guide
This booklet covers dental, vision and basic life insurance, benefits available to you with at least one year of state service.
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Legal Plan Booklet
This booklet covers the legal service plan, once you are enrolled.
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Enrollment Forms
Dental/Vision Enrollment and Change Form
Use this form to enroll in or change the dental and vision plans.
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2023 Legal Plan Enrollment Form
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.
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Supplemental Life Enrollment Form
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.
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Group Hospital Indemnity Insurance Enrollment Form
Group Hospital Indemnity Insurance Enrollment Form
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Group Accident Insurance Enrollment Form
Group Accident Insurance Enrollment Form
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Group Critical Illness Enrollment Form
Group Critical Illness Enrollment Form
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Life Insurance Forms
Group Life Insurance Continuation for Laid Off Members
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Beneficiary Form
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.
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Other Forms
Student Eligibility Affidavit
Use this form when your dependent is age 19-23 and attending college.
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Dental and Vision Appeal Form for Union Represented Employees
Use this form when your or your dependents dental and vision coverage has been denied.
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Information
Delta Dental Comparison Chart
A comparison of the Delta Dental network reimbursement.
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Wellness Benefits
This page shows the Wellness Benefit.
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Vision Plans Comparison Chart
A comparison of the vision plans.
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Supplemental Life Insurance Eligibility
This page shows supplemental life eligibility.
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Dependent Eligibility
This page shows dental and vision dependent eligibility.
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Basic Life Imputed Income
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Claim Forms
Dental Claim Form
When using a non-network dentist, download, print and take this form with you.
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VSP Out of Network Claim Form
If you have VSP, and are using a non-network provider, download, print and take this form with you.
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EyeMed Out of Network Claim Form
If you have EyeMed, and are using a non-network provider, download, print and take this form with you.
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Dental Claims Appeal Procedure
Use this information to request a formal appeal of your denied dental claim.
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How to submit a claim online in 3 Steps
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