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:
Insurance Forms
- Liberty Mutual Evidence of Insurability
- Liberty Mutual LTD Enrollment/Change Form
- The Standard Enrollment/Change Form
- The Standard Medical Statement Form
- United Concordia Dental Claim Form
- Superior Vision Claim Form
- Allstate Cancer Claim Form
- Allstate Cancer Wellness Form
- Allstate Cancer EOI Form
- MetLife Claim Form (living)
- MetLife Claim Form (deceased)
- Gerber Life Voluntary AD&D Conversion Option Form
- Gerber Life Voluntary AD&D Waiver of Premium
- Gerber Life Voluntary AD&D Portability Conversion Comparison
- ING Term Life EOI Form
- ING Term Life Death Claim Form
- ING Term Life Continuation Form
- ING Term Life Conversion Form
- ING Term Life Wavier of Premium 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
To retrieve the TSERS forms below go to NC ORBIT. Then navigate to FORMS then Beneficiary Designation Forms. Finally select the desired form from the available list.
- TSERS 2DB-Designating Beneficiary(ies) for the Death Benefit
- TSERS 2RC-Designating Beneficiary(ies) for Retirement System Return of Contributions
- TSERS 6-Claiming Your Retirement Benefit
- Highlights of Your Retirement Benefits Teachers' and State Employees' Retirement System
- Highlights of Your Retirement Benefits Teachers' and State Employees' Retirement System for State Law Enforcement Officers
- Return to Work Laws for TSERS
Disability Forms
To retrieve the disability forms below go to NC ORBIT. Then navigate to FORMS then Disability Application Forms. Finally select the desired form from the available list.
- 701-Requesting the Short-Term of Benefits through the Disability Income Plan of North Carolina
- 703-Medical Report for Eligibility Review of Short-Term Disability Benefits
- 7A-Medical Report for Disability Eligibility Review
