About the Archdiocese
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About the Archdiocese
//
Offices
//
Leadership
//
Contact
//
Events
Sacraments
Reconciliation
Baptism
Holy Orders
Marriage
Confirmation
Holy Communion
Anointing of the Sick
Services and Resources
For Those in Need
For Families
For Vocations
For Young People
Stewardship
For Intercultural Communities
Get Involved
Grow Your Faith
Learn Your Faith
Know the Issues
Promise To Protect
Statements
Resources
Frequently Asked Questions
Glossary of Terms
Investigatory Process
List Release
Give
Education
Search
Human Resources
//
Employee Benefits and Forms
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Forms
Human Resources
Employment Opportunities
Staff
Employee Self Service
Employee Benefits and Forms
Employee Handbooks
Employee Benefits Booklet
Forms
United Healthcare Medical Plan
Delta Dental
Vision Plan
Flexible Spending Account (FSA) Plans
403b Retirement Plan
Life Insurance Plans
Long Term Disability
Employee Assistance Program
Employee Wellness Programs
Administration
Communication Corner
Open Enrollment
Ending Employment
314.792.7540
314.792.7549
[email protected]
20 Archbishop May Dr.
St. Louis, MO 63119-5738
Get Directions
Forms
Health Insurance:
Employee Health Insurance Form
- Enrollment/Change
Employee Health Insurance Waiver Form
- New Hires (
must
be completed if not electing Archdiocese coverage)
OptumRX Mail Order Form
UHC Medical Claim Form
Disabled Dependent Child Certification Form
Flexible Spending Account (FSA):
Flexible Spending Plan Election Form
- Enrollment/Change
FSA Direct Deposit Form
Medical Reimbursement Claim Form
Dependent Care Reimbursement Claim Form
Basic Life and Supplemental Life Insurance:
Beneficiary Designation Form
- Used for both basic and supplemental life coverage.
Supplemental Life Insurance Form
- Enrollment/Change/Cancel
Evidence of Insurability (EOI)
- To apply for additional coverage.
Life Conversion & Portability Form
Life/AD&D Insurance Claim Form
Long Term Disability (LTD):
LTD Claim Form
- To apply for long term disability benefits.
Employee Wellness Program:
Employee Wellness Form
- Submit for a physician's wellness check for the Wellness Plan year effective 5/1/2022 through 4/30/2023.