Benefits Guide and Rates
Benefits Election/Change Summary Forms
Legal Shield (Legal Service/IdentityTheft Shield Plan)
Flexible Spending Account - Health Care and Dependent Care Plan
Summary Annual Report
Research Scholar Assistant
2017 Benefits Information
- 2017 Benefits Open Enrollment Welcome Memo
- 2017 Benefits Open Enrollment Newsletter (highlights changes for 2017)
- 2017 Benefits Guide (includes benefit plan and rate information)
- 2017 Benefits Open Enrollment Instructions
- 2017 Benefits Election/Change Summary - Form #3075 (Word version)
- 2017 Benefits Election/Change Summary - Form #3075 (Adobe version)
- 2016 Benefits Election/Change Summary- Form #3075 (Word version)
- 2016 Benefits Election/Change Summary - Form #3075 (Adobe version)
- AHL PPO - Enrollment Application
- HAP HMO - Enrollment Application (see NOTE below)
- HAP Membership and Record Change Form
NOTE: HAP HMO Enrollment Application must include HAP HMO Personal Care Physician's Name and PCPIN information available on the HAP web site at www.hap.org.
Summary of Benefits and Coverage
The Summary of Benefits and Coverage (SBC) documents below show what the medical plans cover and what they cost.
AHL PPO Plan Information:
HAP HMO Plan Information:
- HAP HMO - SBC Enhanced Benefits
- HAP HMO - SBC Standard Benefits
- HAP HMO - Enhanced and Standard - Schedule of Benefits
- HAP HMO Aspire Health Engagement Membership Guide and Requirements
- HAP HMO Aspire Health Engagement 2017 Deadline Information
HAP/AHL Pharmacy Mail Order Information
New Health Insurance Marketplace Coverage Options and Your Health Coverage
The New Health Insurance Marketplace Coverage Options and Your Health Coverage Notice provides some basic information about the Marketplace and employment-based coverage offered by LTU. For more information about the options that may be available to you through the government's Health Insurance Marketplace, visit www.healthcare.gov.
- Reliance Standard Life Insurance Enrollment/Change Form
- Reliance Standard Beneficiary Designation Form Only
NOTE: Indicate your 2017 FSA Health Care and/or Dependent Care election(s) on the 2017 Benefits Election/Change Summary Form #3075 (above).
The maximum annual amount for the FSA Health Care plan is $2,550.00 and FSA Dependent Care plan is $5,000.00.
- Summary Annual Reports (Health, Life/AD&D/Long Term Disability and Retirement Plans)
- 2017 RSA Open Enrollment Newsletter (highlights changes for 2017)
- 2017 RSA Insurance Guide (Guide includes insurance plan and rate information)
- 2017 RSA Insurance Election/Change Form #3076
Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Office of Human Resources reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. Lawrence Tech in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.