Contact Michelle Cabana at 435-652-7523 or firstname.lastname@example.org for questions.
Public Employees Health Plan
PEHP Flexible Spending Forms:
Family and Medical Leave Act Forms:
- FMLA DSU Application (pdf)
- FMLA Medical Certification (pdf)(for Employee)
- FMLA Medical Certification (pdf)(for a Family Member)
Hartford Life Insurance:
- Hartford Benefit Highlights (pdf) An overview of the life insurance plans being offered at DSU.
- Hartford Beneficiary Designation (pdf) Add or change your basic life insurance beneficiary at any time by completing a beneficiary form and returning the completed form to the Human Resources office. The beneficiary designation with the most recent date, in good form and properly signed, constitutes the only effective designation.
- Life Insurance Policy Provision Summary of scheduled of insurance coverage.
- Hartford Supplemental Life Insurance Application (pdf) Supplemental Life Insurance is additional life insurance coverage that the benefited University employee pays for the premium.
- Hartford Supplemental Rate Sheet (pdf) Use this form to estimate the coverage and calculate the premium. This worksheet does not serve as the enrollment form.
- Hartford Travel Assistant & ID Theft Protection Services (pdf)
DSU Tuition Waiver Program
For benefited University employees, including those retired, and their spouses and eligible dependents.