2025 New Hire Benefits Enrollment Forms

If you are a new hire or rehire at the University of St. Thomas, complete these forms to sign up for your benefits!

BENEFITS ENROLLMENT FORMS

Welcome (or welcome back) to the University of St. Thomas! This online form will allow you to enroll in benefits with the University. Before submitting this form, please make sure that you read through the Benefits Guide to ensure you are aware of your options for each benefit.

Even if you decide to waive coverage, you will need to submit the following required benefits enrollment forms unless otherwise indicated. Please submit the required forms as soon as possible, but no later than 30 days from your first day of employment as a benefits-eligible employee. Please review each section carefully to ensure all required items have been completed. If you have questions about anything on this form, please submit your question to AskHR and a member of the Benefits team will follow up with you as soon as possible.

Benefits Election Form

Complete and submit this form to:
  • Enroll or waive medical, dental and/or vision coverage;
  • Contribute to a health savings account, and/or
  • Contribute to a health care and/or dependent care flexible spending account
Legal Sex
Legal Sex
Employee Type
Employee Type

Section 1: Medical Insurance Coverage Choices

Administered by United Healthcare.
Medical Coverage Enrollment Options
Medical Coverage Enrollment Options

If you select Start New Coverage, plan options will appear for you to select from. If you select Waive Coverage or Keep Current Coverage, no plan options will appear and you can skip to the next section.

  Coverage Level Choice Plus Network
Biweekly Rate		 Core Network
Biweekly Rate
Plan 1 Employee Only $121.67 $109.65
Employee + Spouse $309.28 $277.14
Employee + Child(ren) $283.51 $254.04
Employee + Family $446.74 $400.31
Plan 2 Employee Only $67.15 $59.84
Employee + Spouse $194.14 $173.74
Employee + Child(ren) $177.96 $159.26
Employee + Family $280.42 $250.96
Medical - Select your plan, network and coverage level from the below list.
Medical - Select your plan, network and coverage level from the below list.

Section 2: Dental Insurance Coverage Choices

Administered by Delta Dental.


 
Dental Coverage Enrollment Options
Dental Coverage Enrollment Options

If you select Start New Coverage, plan options will appear for you to select from. If you select Waive Coverage or Keep Current Coverage, no plan options will appear and you can skip to the next section.

Coverage Level Enhanced Dental
Biweekly Rate		 Basic Dental
Biweekly Rate
Employee Only $14.83 $9.67
Employee + Spouse $30.85 $19.50
Employee + Child(ren) $34.03 $27.02
Employee + Family $50.86 $33.23
Dental - Select your plan and coverage level from the below list.
Dental - Select your plan and coverage level from the below list.

Section 3: Vision Insurance Coverage Choices

Administered by EyeMed.


 
Vision Coverage Enrollment Options
Vision Coverage Enrollment Options

If you select Start New Coverage, plan options will appear for you to select from. If you select Waive Coverage or Keep Current Coverage, no plan options will appear and you can skip to the next section.

Vision - Select your coverage level from the below list.
Vision - Select your coverage level from the below list.

Section 4: Health Saving Accounts & Flexible Spending Accounts

Administered by Alerus.



When deciding how much to contribute, review lists of eligible expenses and spending account rules.
When no amounts are listed below, that will indicate that you have elected not to contribute to a spending account(s) for the 2025 plan year.
Health Savings Account (HSA)
ONLY available if electing Plan 2.

 
  Plan 2 - UST Contribution Annual Maximum (Age 54 & below) Annual Maximum (Age 55+)
Employee Only $250 $4,300 - $250 = $4,050 $5,300 - $250 = $5,050
Employee + Spouse $300 $8,550 - $300 = $8,250 $9,550 - $300 = $9,250
Employee + Children $300 $8,550 - $300 = $8,250 $9,550 - $300 = $9,250
Family $500 $8,550 - $500 = $8,050 $9,550 - $500 = $9,050









 
Health Care Flexible Spending Account (FSA)
ONLY available if electing Plan 1
2025 Annual Limit: $3,300 - Minimum if elected is $100
Dependent Care Flexible Spending Account (FSA)
No plan requirements.
2025 annual limit: $5,000 - minimum if elected is $120

Section 5: Eligibility Information

COMPLETE THIS SECTION ONLY IF YOU ARE ADDING FAMILY MEMBERS TO YOUR BENEFITS.

Required Information: Last Name, First Name, Social Security Number, Legal Sex (M/F), Relationship to You, and Date of Birth

If you are adding family members to any of the coverages above, you must submit the required documentation to AskHR to verify their eligibility within 30 days of hire or eligibility date.
You can review the Family Member Eligibility Matrix for more details. If the required documentation is not provided, the affected dependent will be dis-enrolled retroactive to your benefits effective date.

NOTE: Please provide spouse/dependent Social Security Numbers in the section below.
This information is required by the Affordable Care Act and our office will not be able to process your election(s) without this information.
The information provided in this form will only be accessible to employees in the Benefits office for purposes of processing your elections.
Coverage Type Requested for this Family Member
Coverage Type Requested for this Family Member
I would like to add another family member (If no, skip to next section)
I would like to add another family member (If no, skip to next section)
Coverage Type Requested for this Family Member
Coverage Type Requested for this Family Member
I would like to add another family member (If no, skip to next section)
I would like to add another family member (If no, skip to next section)
Coverage Type Requested for this Family Member
Coverage Type Requested for this Family Member
I would like to add another family member (If no, skip to next section)
I would like to add another family member (If no, skip to next section)
Coverage Type Requested for this Family Member
Coverage Type Requested for this Family Member
I would like to add another family member (If no, skip to next section)
I would like to add another family member (If no, skip to next section)
Coverage Type Requested for this Family Member
Coverage Type Requested for this Family Member
I would like to add more than 5 family members, and would like HR to follow up with me for their information.
I would like to add more than 5 family members, and would like HR to follow up with me for their information.
By signing below, I certify that I have received the materials explaining the University of St. Thomas Cafeteria Plan and my program options I understand that by signing and submitting this form, I am making a binding election for the options indicated above. I understand I cannot change these elections except as described in the benefit materials and that any amounts remaining in my reimbursement accounts shall be forfeited in accordance with the plan rules. I hereby authorize the pre-tax deductions indicated above.
Signature - Medical, Dental, Vision, HSA/FSA
Signature - Medical, Dental, Vision, HSA/FSA

The Hartford - Life & Accident Insurance

All eligible UST employees are covered by the Basic Life Insurance policy.
UST provides a policy that covers 2x your annual salary up to a maximum $200,000 benefit. There is no cost to you for this coverage. 
This section is for electing additional voluntary life insurance beyond the UST-provided amount.

Instructions:
  • Please review the applicable benefit highlight/summary information for each product prior to electing coverage.
  • You (employee) and your dependent(s) (if applicable) are only eligible for coverage as allowed by the applicable group policy.
  • Rates can be found here: Voluntary Life Insurance Rates
  • For each coverage, please check the appropriate boxes or decline coverage and enter amounts where necessary. 

Section 1: Voluntary Term Life Insurance

You must enroll for this coverage in order for your dependents to be eligible for this coverage.
For Employee and Spouse coverage, monthly premiums are determined by you and your spouse's age and the coverage amount selected.
For Child coverage, monthly premiums are defined below.
Employee - Voluntary Life Insurance Coverage Amount (select 1)
Employee - Voluntary Life Insurance Coverage Amount (select 1)
Spouse - Voluntary Life Insurance Coverage Amount (select 1)
Spouse - Voluntary Life Insurance Coverage Amount (select 1)
Child - Voluntary Life Insurance Coverage Amount (select 1)
Child - Voluntary Life Insurance Coverage Amount (select 1)
Additional Information about Voluntary Life Insurance
  • ​​​​If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $200,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you wlil need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.
  • If you are newly eligible and elect and amount that exceeds the guaranteed issue amount of $50,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you wlil need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.
  • The premium amount(s) for you and your spouse are based on your respective age; therefore, the premium amount(s) will change as you or your spouse grow older.
  • The benefit amount available to you (employee) under this plan is subject to a reduction schedule beginning at age 65.
  • The child benefit amount applies to any child age 6 months or older. A different amount may apply to any child under the age of 6 months.

Section 2: Voluntary Accidental Death & Dismemberment (AD&D) Insurance

You must enroll for this coverage in order for your dependents to be eligible for this coverage.
Employee - Voluntary AD&D Insurance Coverage Amount (select 1)
Employee - Voluntary AD&D Insurance Coverage Amount (select 1)
Spouse - Voluntary AD&D Insurance Coverage Amount (select 1)
Spouse - Voluntary AD&D Insurance Coverage Amount (select 1)
Child - Voluntary AD&D Insurance Coverage Amount (select 1)
Child - Voluntary AD&D Insurance Coverage Amount (select 1)

Section 3: Beneficiary Designation

Please ensure your beneficiary designation is clear so there is no question of your intent.

This designation is for all group insurance coverage issued by The Hartford for which benefits are payable to a beneficiary or survivor (as indicated by each specific policy) in the event of your death, unless otherwise requested by you in writing. This desigation may be changed upon written request. All information requested is required, per beneficiary. If more than one beneficiary is named, the beneficiaries shall share benefits equally unless percentages are stated below. The percentages must total 100% for all Primary Beneficiaries and 100% for all Contingent Beneficiaries. Please consult your beneifts administrator or legal advisor for assistance or additional information.

Primary Beneficiaries

Primary Beneficiaries are first in line to receive benefits if living at the time of your death.
Please enter the following information for each Primary Beneficiary you would like to designate:
  • Name (First MI Last)
  • Date of Birth
  • Social Security Number
  • Relationship to You (e.g. Spouse, Parent, Sibling, etc.)
  • Percent
  • Address (Street, City, State & ZIP)
  • Phone Number.
You must add at least 1 primary beneficiary to submit this form. You may add up to 6 primary beneficiaries on this form. If you need to designate more beneficiaries than space will allow, please check the box at the bottom of this section and Human Resources will follow up with you.
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add another primary beneficiary (If no, skip to next section)
I would like to add more than 6 primary beneficiaries, and would like HR to follow up with me for their information.
I would like to add more than 6 primary beneficiaries, and would like HR to follow up with me for their information.

Contingent Beneficiaries

Contingent(s) will receive benefits if no primary beneficiary is alive at the time of your death. Please enter the following information for each Contingent Beneficiary you would like to designate:
  • Name (First MI Last)
  • Date of Birth
  • Social Security Number
  • Relationship to You (e.g. Spouse, Parent, Sibling, etc.)
  • Percent
  • Address (Street, City, State & ZIP)
  • Phone Number.
You can add up to 6 contingent beneficiaries on this form. If you need to designate more beneficiaries than space will allow, please check the box at the bottom of this section and Human Resources will follow up with you.
If you do not want to designate any contingent beneficiaries, you may leave this space blank.
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add another contingent beneficiary (If no, skip to next section)
I would like to add more than 6 contingent beneficiaries, and would like HR to follow up with me for their information.
I would like to add more than 6 contingent beneficiaries, and would like HR to follow up with me for their information.

Section 4: Fraud Warning Statements

Please follow this link to read the statement that applies to your state of residence prior to submitting this enrollment form.

The Hartford - Important Notice - Fraud Warning Statements

Group Long Term Disability Tax Election Form

Taxation of Disability Benefits: Internal Revenue Code (IRC) Section 105 indicates that Long Term Disability (LTD) benefits are to be included in the gross income of employee if the employer, University of St. Thomas (UST), pays part or all of the premium for the coverage. As such, you have the option to pay for your LTD benefit with pre or post tax dollars.

There are 2 scenarios:
  1. If UST pays the entire LTD premium, then the disability benefits received are 100% taxable to the employee.
  2. If you choose to be taxed on the premium that UST pays (called a gross up), then the benefits received are not taxable.

Examples to Consider:
 
Two LTD Scenarios $40,00 annual income $70,000 annual income
After tax (30%) take home $28,000 After tax (30%) take home $49,000
Pre-tax contributions Post-tax contributions Pre-tax contributions Post-tax contributions
LTD Monthly Premium $4.20 $4.20 $7.35 $7.35
Increased annual salary due to gross up N/A $50.40 N/A $88.20
Monthly tax on premium N/A $1.26 N/A $2.21
Monthly LTD benefit when disabled $2,000 $2,000 $3,500 $3,500
Monthly Tax on LTD benefit (30%) $600 N/A $1,050 N/A
Total LTD monthly payment $1,400 $2,000 $2,450 $3,500
Income Replacement ratio 60% 86% 60% 86%

You may want to consult with your financial advisor prior to your decision. The majority of the time, most will recommend post-tax when it's available. This results in a tax-free LTD payment accomplishing two things: lowering one's tax obligation when finances might be tight during a disability, and even though the benefit is paid at 60% of your base salary, considering the LTD payment is tax free gets you closer to pre-disability earnings. 
Group LTD Tax Election - Please select one of the following:
Group LTD Tax Election - Please select one of the following:
I understand that my election is irrevocable until I provide written confirmation to the Benefits Office that I wish to change my election. My next opportunity to change this election will be during an Open Enrollment period. If I have elected to pay taxes on the premium (Option 2), I understand that the imputed income amount can change during the plan year if there are any changes to my salary or the LTD rate.
Signature - Group LTD Tax Election
Signature - Group LTD Tax Election

MetLife Enrollment Form

Administered by MetLife



If you wish to enroll in MetLife's Legal Plan, the payroll deduction will be $18.90 per month ($9.45 per pay period) for this benefit.

If you wish to enroll in MetLife's AURA Identity Theft & Fraud Protection Plan, the payroll deduction will be $8.95 per month ($4.48 per pay period) for Employee Only and $14.95 per month ($7.48 per pay period) for Employee + Family.

By enrolling in these benefits, I authorize University of St. Thomas to take the appropriate after-tax payroll deductions needed to maintain this coverage. I understand that coverage will remain in effect for the entire plan year, starting on my first day of coverage, unless I am no longer an eligible employee of the University of St. Thomas.
MetLife Legal Plan Enrollment Choice
MetLife Legal Plan Enrollment Choice
MetLife AURA Identity Theft & Fraud Protection Enrollment Choice
MetLife AURA Identity Theft & Fraud Protection Enrollment Choice

Voya Enrollment Form

Administered by Voya Financial



For Critical Illness Insurance for Employee, Spouse and Dependents, rates are based on the employee or spouse's attained age as of January 1st of the calendar year, and the coverage amount selected.
Please ensure you review the rate tables found on page 3 and page 4 here: 2025 Rates

Please note that for all Voya benefits, employee coverage is required in order to elect Spouse and Children coverage.

By enrolling in these benefits, I authorize University of St. Thomas to take the appropriate after-tax payroll deductions needed to maintain this coverage.
I understand that coverage will remain in effect for the entire plan year, starting on my first day of coverage, unless I am no longer an eligible employee of the University of St. Thomas.
Voya Accident Insurance Enrollment Choice
Voya Accident Insurance Enrollment Choice
Voya Hospital Indemnity Insurance Enrollment Choice
Voya Hospital Indemnity Insurance Enrollment Choice
Critical Illness Coverage
An employee may elect Critical Illness Insurance coverage at the $10,000, $20,000, or $30,000 coverage level.
Employee coverage must be elected in order to elect Spouse or Children coverage.
The coverage amount for Spouse and Children will be equivalent to 50% of the Employee coverage amount selected.

Employee Amount: $10,000 = Spouse/Child Amount: $5,000
Employee Amount: $20,000 = Spouse/Child Amount: $10,000
Employee Amount: $30,000 = Spouse/Child Amount: $15,000
Voya Critical Illness Insurance - Employee Enrollment Choice
Voya Critical Illness Insurance - Employee Enrollment Choice
Voya Critical Illness Insurance - Spouse Enrollment Choice
Voya Critical Illness Insurance - Spouse Enrollment Choice
Voya Critical Illness Insurance - Child(ren) Enrollment Choice
Voya Critical Illness Insurance - Child(ren) Enrollment Choice
Once all forms are completed, please click the "Submit" button below. Thank you!

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