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Forms

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SEND ALL FORMS TO:  Benefits & Retirement
                                              600 Henley Street
                                              Suite #115
                                              Knoxville, TN 37996-4115

Deferred Compensation Forms
Retiree Insurance Forms
Long Term Disability Forms
TCRS/ TCRS Hybrid Forms
ORP/ ORP Hybrid Forms
UT & Miscellaneous Forms

401(k) Agreement for Deferral of Lump Sum Annual Leave - form 1 (form 1&2 Required) -to defer annual leave at the time of termination to the 401(k) plan form1
401(k) Agreement for Deferral of Lump Sum Annual Leave - form 2 (form 1&2 Required) -to defer annual leave at the time of termination to the 401(k) plan form2
401(k) Beneficiary Designation form - for naming or changing your 401(k) beneficiary
401(k) Enrollment - for 401(k) new enrollments
401(k) Enrollment and/or changes - for online enrollment or changes  to the 401(k) plan 
401(k) Hardship Withdrawal Request - for 401(k) plan hardship withdrawal
401(k) Incoming Rollover - for making rollovers in to the 401(k) plan
401(k) Loan Application - borrow against your 401(k) balance
401(k) Longevity Deferral - for electing deferral of annual longevity payment in to your 401(k) plan
401(k) Participant Change Request - for name or address changes to 401(k) plan
401(k) Plan Distribution Request - for 401(k) total or partial lump sum withdrawals or rollovers out of the plan please contact Empower-Retirement at (800) 922-7772 option 2 or local Nashville at (615) 244-1030. 
401(k) Salary Reduction Agreement - for 401(k) deferral amount increases, decreases, or cancellations
403(b) Agreement for Deferral of Lump Sum Annual Leave - form 1 (form 1&2 Required)to defer annual leave at the time of termination to the 403(b) plan - form 2
403(b) Agreement for Deferral of Lump Sum Annual Leave - form 2 (form 1&2 Required)to defer annual leave at the time of termination to the 403(b) plan - form 1
403(b) Enrollment - for 403(b) new enrollments 
403(b) Salary Reduction Agreement - for deferral amount increases, decreases, or cancellations in the 403b plan
403b Plan Distribution Request - for 403b  total or partial lump sum withdrawals or rollovers out of the plan please contact the 403b provider (Ameriprise, Fidelity, TIAA-CREF, VALIC, VOYA)
457 Agreement for Deferral of Lump Sum Annual Leave - form 1 (form 1&2 Required) to defer annual leave at the time of termination  to the 457 plan -
form 1
457 Agreement for Deferral of Lump Sum Annual Leave - form 2 (form 1&2 Required) to defer annual leave at the time of termination  to the 457 plan -
form 2
457 Beneficiary Designation - for naming or changing your 457 beneficiary
457 Catch-Up - enroll in participation in special Standard Catch-Up in 457 plan
457 Enrollment- for 457 new enrollments 
457 Enrollment and/or changes - for online enrollment or changes to the 457 plan 
457 Hardship Withdrawal Request - for 457 plan hardship withdrawal
457 Incoming Rollover - for making rollovers in to the 457 plan
457 Longevity Deferral - for electing deferral of annual longevity payment into your 457 plan
457 Participant Change Request - for name or address changes to 457 plan
457 Plan Distribution Request - for 457 total or partial lump sum withdrawals or rollovers out of the plan please contact Empower-Retirement at (800) 922-7772 option 2 or local Nashville at (615) 244-1030. 
457 Salary Reduction Agreement - for 457 deferral amount increases, decreases, or cancellations and longevity deferrals
ACH Direct Billing - for authorization of insurance premiums for retiree coverage
Additional Retirement Credit: TCRS - for TCRS credit of additional retirement service
Address/Name Change Request 401(k) - for name or address changes to 401(k) plan
Address/Name Change Request 457 - for name or address changes to 457 plan
Address/Name Change Request: TCRS - for name or address changes your TCRS information
Annual Leave 401(k ) - form 1 (form 1&2 Required) to defer annual leave at the time of termination to the 401(k) plan:form 2
Annual Leave 401(k) - form 2 (form 1&2 Required) to defer annual leave at the time of termination to the 401(k) plan:form 1
Annual Leave 403(b) - form 1 (form 1&2 Required) to defer annual leave at the time of termination to the 403(b) plan:form 2
Annual Leave 403(b) - form 2 (form 1&2 Required) to defer annual leave at the time of termination to the 403(b) plan:form 1
Annual Leave 457 - form 1 (form 1&2 Required)to defer annual leave at the time of termination to the 457 plan:form 2
Annual Leave 457 - form 2 (form 1&2 Required)to defer annual leave at the time of termination  to the 457 plan:form 2
Annual Statement: TCRS - for all forms and reviewing your salary and service reported  to TCRS
Application for Refund of Accumulated Contributions: TCRS - for TCRS Hybrid refunds of accumulated contributions
Application for Retirement: TCRS - for TCRS early or service retirement
Beneficiary Designation: TCRS - for naming or changing your TCRS beneficiary
Beneficiary Designation form: 401(k) - for naming or changing your 401(k) beneficiary
Beneficiary Designation form: 457 - for naming or changing your 457 beneficiary
Beneficiary Designation TSP-3: TSP - for naming or changing your TSP beneficiary
Continuation of Medical Insurance Application - for keeping insurance in retirement
Continuation of UserId and Email Account in Retirement - for retiring faculty/staff to retain their email and UserId
Deferral of Lump Sum Annual Leave 401(k) - form 1 (form 1&2 Required) to defer annual leave at the time of termination to the 401(k) plan:form 1
Deferral of Lump Sum Annual Leave 401(k) - form 2 (form 1&2 Required) to defer annual leave at the time of termination to the 401(k) plan:form 2
Deferral of Lump Sum Annual Leave 403(b) - form 1 (form 1&2 Required) to defer annual leave at the time of termination to the 403(b) plan: form 2
Deferral of Lump Sum Annual Leave 403(b) - form 2 (form 1&2 Required) to defer annual leave at the time of termination to the 403(b) plan:form 1
Deferral of Lump Sum Annual Leave 457 - form 1 (form 1&2 Required) to defer annual leave at the time of termination  to the 457 plan:form 1
Deferral of Lump Sum Annual Leave 457 - form 2 (form 1&2 Required) to defer annual leave at the time of termination  to the 457 plan:form 2
Disability Insurance Claim - for filing a long term disability insurance claim for benefits
Disability Retirement (Disability Application): TCRS - for TCRS disability retirement
Disability: Attending Physicians Report of Disability: TCRS - for certification by physician for disability retirement
Disability: Medical Records Release Authorization: TCRS - for release of medical records for disability retirement
Disability: Statement of Disability: TCRS - for employee statement of disability
Disability: Vocational History : TCRS - for employee statement of job and training history
Educational Leave of Absence: TCRS - for TCRS credit for education leave of absence
Email Account in Retirement - for retiring faculty/staff to retain their email and UserId
Enrollment 401(k) - for 401(k) new enrollments
Enrollment 403(b) - for 403(b) new enrollments 
Enrollment 457 - for 457 new enrollments 
Enrollment and/or changes 401(k) for online enrollment or changes to the 401(k) plan 
Enrollment and/or changes 457 for online enrollment or changes to the 457 plan 
Enrollment or Change to TSP Contributions - for new enrollment in TSP or for  increases, decreases, or cancellations in the TSP plan
Hardship Withdrawal Request 401(k) - for 401(k) plan hardship withdrawal
Hardship Withdrawal Request 457 - for 457 plan hardship withdrawal
Incoming Rollover 401(k) - for making rollovers in to the 401(k) plan
Incoming Rollover 457 - for making rollovers in to the 457 plan
Lifetime Distribution Exception: ORP - for ORP distribution of funds for prior employees
Loan Application 401(k)  - to borrow against your 401(k) balance
Long Term Disability Cancellation - for cancelling LTD coverage
Long Term Disability Claim - for filing a long term disability claim for benefits
Long Term Disability Enrollment - form 1 (Exempt Employee) for enrollment in to the LTD plans
Long Term Disability Enrollment - form 2 (Non-Exempt Employee) for enrollment in to the LTD plans
Long Term Disability Late Enrollment - form 2 (form 1&2 Required) for late enrollment in to the LTD plans after the first 90 days of employement
Longevity Deferral 401(k) - for electing deferral of annual longevity payment in to your 401(k) plan
Longevity Deferral 457 - for electing deferral of annual longevity payment in to your 457 plan
LTD Cancellation - for cancellation of Long Term Disability Insurance
LTD Disability Claim - for filing a long term disability insurance claim for benefits
LTD Enrollment - form 1 (Exempt Employee) for enrollment in to the LTD plans
LTD Enrollment - form 1 (Non-Exempt Employee) for enrollment in to the LTD plans
LTD Late Enrollment- form 2 (form 1&2 Required) for late enrollment in to the LTD plans after the first 90 days of employement
Military Service Retirement Credit : TCRS - for TCRS credit of military service 
Notice of Election to Participate in the ORP - for electing the ORP (Exempt only) retirement plan
Notice of Election to Participate in the TCRS - for electing the TCRS (Exempt only) retirement plan
ORP: Lifetime Distribution Exception - for ORP distribution of funds  for prior employees
Enrollment and/or changes to ORP - TIAA-CREF for online access  to the ORP or 403b accounts  to enroll or change
Enrollment and/or changes to ORP - VALIC for online access  to the ORP or 403b accounts  to enroll or change
Enrollment and/or changes to ORP - VOYA for online access  to the ORP or 403b accounts  to enroll or change
ORP: TIAA-CREF for online access to the ORP or 403b accounts  to enroll or change
ORP: VALIC for online access  to the ORP or 403b accounts  to enroll or change
ORP: Verification of Employee Termination - for ORP verification of prior employee termination date
ORP: VOYA for online access  to the ORP or 403b accounts  to enroll or change
Post Retirement Agreement - for rehiring retiring faculty 
Premium Distribution form - for exempt employees enrollment in to a retirement plan
Reemployment: 120-Day Temporary Employment Report - for re-employement of all retirees collecting a retirement benefit
Refund of Accumulated Contributions: TCRS Hybrid - for TCRS refunds of accumulated contributions
Rehire: 120-Day Temporary Employment Report - for re-employement of all retirees collecting a retirement benefit
Retiree Reemployment: 120-Day Temporary Employment Report - for re-employement of all retirees collecting a retirement benefit
Retirement Credit for a Period of Temporary Disability: TCRS - for TCRS credit of Workers' Compensation time out
Salary Reduction Agreement 401(k) - for 401(k) deferral amount increases, decreases, or cancellations
Salary Reduction Agreement 403(b) - for deferral amount increases, decreases, or cancellations in the 403b plan
Salary Reduction Agreement 457 - for 457 deferral amount increases, decreases, or cancellations and longevity deferrals
Salary Reduction Agreement TSP - for new enrollment in TSP or  for  increases, decreases, or cancellations in the TSP plan
Standard Catch-Up 457 - to enroll in participation in special Standard Catch-Up in 457 plan
TCRS: Annual Statement- for all forms and reviewing your active employee salary and service reported to TCRS
TCRS: Application for Additional Retirement Credit - for TCRS credit of additional retirement service
TCRS: Application for Disability Retirement (Disability Application) - for TCRS disability retirement
TCRS: Application for Military Service Retirement Credit - for TCRS credit of military service 
TCRS: Application for Refund of Accumulated Contributions - for TCRS Hybrid refunds of accumulated contributions
TCRS: Application for Retirement - for TCRS early or service retirement
TCRS: Application for Retirement Credit for a Period of Temporary Disability - for TCRS credit of Workers' Compensation time out
TCRS: Application for Retirement Credit for Educational Leave of Absence - for TCRS credit for education leave of absence
TCRS: Change of Beneficiary - for naming or changing your TCRS beneficiary
TCRS: Member Information Change - for name or address changes your TCRS information
TCRS: Notice of Election to Participate in the ORP or TCRS - for electing the TCRS retirement plan
TCRS-Disability: Attending Physicians Report of Disability - for certification by physician for disability retirement with TCRS
TCRS-Disability: Medical Records Release Authorization - for release of medical records for disability retirement with TCRS
TCRS-Disability: Statement of Disability - for employee statement of disability with TCRS
TCRS-Disability: Vocational History - for employee statement of job and training history with TCRS
TCRS: Withdrawal Request - TCRS Hybrid - for TCRS Hybrid refunds of accumulated contributions
TIAA-CREF: ORP - for online access to the ORP or 403b accounts to enroll or change
TSP- Designation of Beneficiary TSP-3 - for naming or changing your TSP beneficiary
TSP Plan Distribution Request - for TSP total or partial lump sum withdrawals or rollovers out of the plan please contact TSP at (877) 968-3778 
TSP-Election form TSP-1 - for new enrollment in TSP or  for  increases, decreases, or cancellations in the TSP plan
UserId and Email Account in Retirement - for retiring faculty/staff to retain their email and UserId
VALIC: ORP for online access to the ORP or 403b accounts to enroll or change
Verification of Employee Termination: ORP - for ORP verification of prior employee termination date
VOYA: ORP - for online access to the ORP or 403b accounts to enroll or change
Withdrawal Request - ORP (TIAA-CREF) - for total or partial lump sum withdrawals or rollovers out of the plan please contact the ORP provider (TIAA-CREF 800-842-2252)
Withdrawal Request - ORP (VALIC) - for total or partial lump sum withdrawals or rollovers out of the plan please contact the ORP provider (VOYA 866-776-6704)
Withdrawal Request - ORP (VOYA) - for total or partial lump sum withdrawals or rollovers out of the plan please contact the ORP provider (VALIC 80-448-2542)
Withdrawal Request - TCRS Hybrid - for TCRS refunds of accumulated contributions
Withdrawal Request - TSP - for TSP total or partial lump sum withdrawals or rollovers out of the plan please contact TSP at (877) 968-3778 
Withdrawal Request 401(k) - for 401(k) total or partial lump sum withdrawals or rollovers out of the plan please contact Empower-Retirement at (800) 922-7772 option 2 or local Nashville at (615) 244-1030. 
Withdrawal Request 403b - for 403b total or partial lump sum withdrawals or rollovers out of the plan please contact the 403b provider (Ameriprise, Fidelity, TIAA-CREF, VALIC, VOYA)
Withdrawal Request 457 -for 457 total or partial lump sum withdrawals or rollovers out of the plan please contact Empower-Retirement at (800) 922-7772 option 2 or local Nashville at (615) 244-1030. 

 

AboUT You 

RESOURCES:

Campus/Institute Contacts:
Chattanooga   
Family Practice- Chatt. 
Health Science Center  
Knoxville Area    
Martin   
UTSI    
UT Memorial Hospital

SEND FORMS TO:
Deferred Compensation (401k, 457, 403b) Forms:
     Total Rewards/ Benefits & Retirement Office
     600 Henley St, #115
     Knoxville, TN  37996-4115

Insurance Forms:
     Insurance & Retirement
     P115 Andy Holt Tower
     1331 Circle Park
     Knoxville, TN  37996-0100

Retirement Forms:
     Total Rewards/ Benefits & Retirement Office
     600 Henley St, #115
     Knoxville, TN  37996-4115

Other Links:
Deferred Compensation (State site)
Deferred Compensation (Empower Retirement site)
Optional Retirement Program (ORP State site)
Tennessee Consolidated Retirement System (TCRS State site)
Office of Personnel Management- OPM (CSRS & FERS)