Benefits Forms: Expanded Long-Term Disability Plan Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
- Expanded
Long-Term Disability Application
For new hires or newly eligible faculty and staff who wish to enroll in Expanded Long-Term Disability.
- Expanded
Long-Term Disability Application with Health Statement
Use this form when more than 30 days have passed since your hire date or date of eligibility, or when you have four or more years of service and wish to increase your coverage over the $30,000 of your base salary that is paid for by the university.
- Expanded
Long-Term Disability Plan Notice of Withdrawal
Use this form to withdraw from participation in the Expanded Long-Term Disability Plan.
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 Benefits Office 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. The University of Michigan 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.