Templates - Employee: Benefits

Cafeteria Plan: Dependent Care Reimbursement and/or Health Care Reimbursement Request - UMR Flexible Spending Reimbursement Form (PDF)

View Policy: CESP 8-21

EBEN-105: Dental Enrollment Application; Cancellation of Coverage; Add/Changes to Coverage (PDF)

View Policy: CESP 8-24

EBEN-106: University of Arkansas Health Insurance Enrollment Application (PDF)

View Policy: CESP 8-2 

EBEN-107: Application for Maternity Leave

View Policy: CESP 7-13

EBEN-108: University of Arkansas Superior Vision Plan Enrollment Application

View Policy: None

EBEN-109: Employee Request - Leave for Study

View Policy: CESP 3-35

EBEN-110: Health Savings Account (HSA) Enrollment Form; (Must be enrolled in the Health Savings Plan)

View Policy: CESP 8-2 

EBEN-112: University of Arkansas Flexible Benefits Plan Enrollment Form (PDF)

View Policy: CESP 8-21

EBEN-226: University of Arkansas Group Benefits Change Form (PDF)

View Policy: None

EBEN-227: University of Arkansas Group Benefits Enrollment Form (PDF)

View Policy: None

EBEN-228: Voluntary Salary Deferral Agreement Form (PDF)

View Policy: None

EBEN-231: Request for Consideration Under the Family and Medical Leave Act

View Policy: UASP 425.1

EBEN-328: Families First Coronavirus Response Act (FFCRA) Leave Request Form

View Policy: None

PMGS 17-A Employee Request for Registration Fee Discount

PMGS 17-B Request for Registration Fee Discount for Spouse