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FORMS and Brochures

Brochures

Summary Plan Description (.PDF)

• Enclosure: ORP Contribution Sheet (.PDF)
• Enclosure: Provider Contact Sheet (.PDF)
• Insert: Group Life Insurance brochure (.PDF)
• Insert: Long Term Disability Insurance brochure (.PDF)

Forms for newly eligible employees

The forms listed below must be provided within 10 business days of an employee’s initial eligibility for ORP coverage. Provider enrollment kits must also be provided and are available from the Department of Higher Education through the ORP Supply Request Form.

Forms are provided as PDF documents for completion and printing. All forms must be physically signed and returned promptly to the Plan Administrator at the Board of Higher Education. Copies should be retained for on-site personnel folders.

• Form SSA-1945 (.PDF)
• ORP Enrollment/Change Form (.PDF)
• Insurance Enrollment/Beneficiary Change Form (.PDF)
• SERS Application to Withdraw Accumulated Pension Deductions (Refund/Rollover Request Form) (.PDF)
• Summary Plan Description (.PDF)

In addition, the Notice of ORP Eligibility (.PDF) form letter and ORP Enrollment Checklist (.PDF) may be used to establish and monitor enrollment deadlines.

Access Participant Data

Click here to access participant information relating to total Years of Creditable Service and Retiree Income on the DHE database.

Forms for changes in participant status

• Change to Ineligible Position
• Leave of Absence Without Pay
• Termination of Employment
• Workload Reduction to less than 50% FTE

Forms available at AdminEase

Several insurance forms are available through Standard Insurance Company's AdminEase using the below directions.

• To print a form using AdminEase:
  • Go to the AdminEase Web site: http://adminease.standard.com
  • Log in using one of the following four Login/Password combinations:
    • Login: ORP1231/Password: ORP1231
    • Login: ORP1232/Password: ORP1232
    • Login: ORP1233/Password: ORP 1233
    • Login: ORP1234/Password: ORP1234
  • Select form:
    • Disability
    • Life Claim (for Accelerated Death Benefits)
    • Continued Benefits (for Conversion forms)
• To order form supplies using AdminEase:
  • Use the steps above to log in to the AdminEase website
  • Select "Order Paper Forms"