Forms

Benefits Forms

Employees electing or changing their health benefits must complete the appropriate form and submit it to Benefits@du.edu no later than 30 days from the IRS Qualifying Life Event.  Supporting document of the qualifying life event and dependent documentation are required.  

Benefits Enrollment Form
New employees or existing employees use this form to elect or change health plans. 

Benefits Cancellation Form
Use this form to cancel health insurance coverage for you and/or your dependents. 


Health Savings Account (HSA) Payroll Deduction Form
Employees enrolled in the Cigna High Deductible Health Plan (HDHP) that have an HSA can make changes to their contributions at any time by completing the HSA Payroll Deduction Form. 


Retirement Plan Participation Waiver of Service 
Employees who worked at least 12 consecutive months in a retirement benefit eligible position at the University of Denver are eligible for the Match Feature immediately with a contribution of 4% or more. You may waive the Retirement Plan’s one-year of service worked if your previous employer is a qualified educational institution and you were retirement benefit eligible under your previous employer’s retirement savings plan.

 


Leave of Absence Forms

Family and Medical Leave Act (FMLA) entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons.

Certification of Health Care Provider for Employee's Serious Health Condition
Employee must submit this medical certification if the employee is seeking leave under FMLA due to their own serious health condition. 

Certification of Health Care Provider for Family Member's Serious Health Condition
Employee must submit this medical certification if the employee is seeking leave under FMLA to care for a family member with a serious health condition. 

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