Benefit Forms and Documents
Complete the Benefits Election/Change Summary Form #3075 and applicable benefit enrollment form(s) listed below. All benefit forms must be received by the Office of Human Resources within 30 days of eligibility. Failure to submit elections within the 30-day deadline will result in no insurance coverage for the entire plan year.
Benefit Forms and Documents 
Benefits Newsletter and Guide
Benefits Election/Change Summary
Medical Insurance
Medical Plans - Summary of Benefits and Coverage
Vision Insurance
Dental Insurance
Life Insurance
Legal Shield (Pre-Paid Legal Service/IdentityTheft Shield Plan)
Flexible Spending Account - Health and Dependent Plan
Waiver of Insurance and Certification of Other Coverage
Retirement Plan
Summary Annual Report (All Plans)
Benefits Newsletter and Guide
2013 Benefits
- 2013 Benefits Open Enrollment Newsletter
- 2013 Benefits Guide
- 2013 Monthly Health Insurance Rates
- 2013 Insurance Providers Contact Information
Benefits Election/Change Summary
- 2013 Benefits Election/Change Summary (Form #3075)
- Affidavit of Domestic Partner Benefits (Form #3032)
Medical Insurance
Effective 01/01/2013
Note: BCN HBL HMO enrollments must include BCN Primary Care doctor's Name, NPI Code and Location. Locate your BCN doctor's information at http://www.bcbsm.com/index/common/find-a-doctor.html.
Plan Information
- BCN Healthy Blue Living HMO Guide & Requirements
- BCN Healthy Blue Living HMO - Schedule of Benefits Summary
- BCBSM Simply Blue PPO - Schedule of Benefits and Blue Preferred Rx Prescription Drug Summary
- Medco Pharmacy Mail Order Form
Medical Plans - Summary of Benefits and Coverage
The Summary of Benefits and Coverage (SBC) documents summarize what the plan covers and what the plan cost. Download a copy of the following SBC documents:
Request a paper copy of the SBC documents free of charge by emailing benefits@ltu.edu
Vision Insurance
Dental Insurance
Life Insurance
Legal Shield (Pre-Paid Legal Service/Identity Theft Shield)
Flexible Spending Account (FSA)
- 2013 FSA - Health Care or Dependent Care Election (Form #3013)
- WageWorks Health Care Claim Form
- WageWorks Dependent Care Claim Form
Waiver of Insurance
Retirement Plan
Summary Annual Reports
Questions? Email benefits@ltu.edu.
Limitations
Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Office of Human Resources reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.
Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Office of Human Resources reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.