Benefits Forms

Below you will find commonly used Insurance, Retirement and Flexible Spending Account Forms. In addition, there may be times that you have to obtain forms directly from some benefit vendors. Here are links to certain vendor Web sites:

• NCFlex Benefit Plan Forms
• Teachers’ and State Employees’ Retirement System Forms
• State Health Plan of North Carolina

Insurance Forms

• Affidavit For Domestic Partner
• Liberty LTD Announcement Open Enrollment
• Liberty Mutual Evidence of Insurability
• Liberty Mutual LTD Enrollment/Change Form
• Liberty Mutual Notice of Information
• Liberty Mutual Supplemental Disability Brochure
• Liberty Mutual Supplemental Disability Enrollment Form
• MetLife Beneficiary Designation Change Form
• MetLife Enrollment/Change Form
• Metlife Statement of Health Form
• Reliance Standard AD&D Enrollment Form
• The Standard Enrollment/Change Form
• The Standard Medical Statement Form
• United Concordia Dental Claim Form
• United Concordia Domestic Partner Enrollment Form

Retirement Forms

• 403(b) Salary Reduction Agreement Form
• ORP-1 Election of the UNC Optional Retirement Program
• ORP-2 Notice of Change in Election for the UNC ORP
• ORP-3 Acknowledgement of Disposition of Account Contributions for the UNC ORP
• ORP-4 Authorization for Coverage Under the State of North Carolina Retiree Group Health Plan
• Retirement Election Form for Faculty and EPA Non-Faculty

Spending Account Forms

• 2012 FSA Claim Form