Get Insurance Enrollment / Change - The University Of Texas At Austin

This guide provides comprehensive instructions for filling out the Insurance Enrollment / Change form for The University of Texas at Austin. Follow these steps to ensure your form is completed accurately and efficiently.

Follow the steps to fill out the Insurance Enrollment / Change form smoothly.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Enter your employee name as it appears in your records at The University of Texas at Austin.
3. Provide your Social Security number (SSN). While disclosure is not legally mandatory, failing to provide it may impact your prior employment information related to benefits.
4. Indicate your start date with UT Austin.
5. Fill in the section requiring the prior state agency or institution to input the dates of your previous employment in MM/DD/YYYY format.
6. Specify the information to be transferred, including your annual leave balance, sick leave balance, and annual benefit replacement pay.
7. Answer whether you were employee benefits eligible any time from September 1, 2003, to the present.
8. Indicate if you satisfied the 90-day insurance waiting period; if not, provide the number of days satisfied.
9. Provide the termination date of any insurance benefits received.
10. Include payroll data such as gross wages, Medicare wages, Medicare deductions, Social Security wages, and Social Security deductions.
11. If applicable, complete the retiree information section with the state retirement (ERS/TRS) date and last day employed prior to retirement.
12. The form must be signed and dated by an authorized representative of the prior state agency or institution, including their name, title, state agency number, email, and phone.
13. Finally, submit the completed form by faxing it to 512-232-3524, addressed to Human Resources — Employee Records at The University of Texas at Austin.

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