Benefits
Benefit Forms
Here are commonly used employee benefit forms.
401K ¦ Beneficiary Changes ¦ Dental ¦ Flexible Spending ¦ Health ¦ Status Change ¦ Other Benefits
Click on the link to open the form.
| 401K | |
| 401(k) Rollover Form | Use this form if you are rolling assets from a former employer’s 401(k) or pension plan into the B&L 401(k) Account. Mail it with your roll-over check to the address indicated. Give a copy to your HR representative. |
| Beneficiary Changes - TOP | |
| Beneficiary Designation Form - Contingent Beneficiary | This form allows you to name contingent (alternative or secondary) beneficiary(s) in the event that the primary beneficiary(s) predeceases the insured. Complete the form and give a copy to your HR representative. Retain a copy for your records. Update it as needed. |
| Beneficiary Designation Form - Life Insurance & 401(k) | Use this form to name a beneficiary(s) for your life insurance and 401(k) plans. You may use the Standard Beneficiary Designation or you may customize your designation. Once the form is completed, give a copy to your HR representative. Save a copy for yourself and be sure to update it if a change is necessary. |
| Beneficiary Designation Form - Steady Growth Account | Use this form if you are unmarried and want to specify a beneficiary to receive assets from the plan in the event of your death. Give the form to your HR representative and retain a copy for your records. If you should marry, your spouse automatically receives assets from the plan in the event of your death. |
| Dental - TOP | |
| Dental Claim Form for Metlife | Participating network dentists will file your claim on your behalf. Use this form to submit your claim if you use a non-network dentist who does not file your claim for you |
| Flexible Spending Account - TOP | |
| Flexible Spending Account (FSA) Claim Form | Use this form for filing either health care or dependent care claims with the UnitedHealthCare FSA unit for reimbursement. Remember that if you are enrolled in a UHC medical plan or the Metlife Dental Plan and use participating providers, your out-of-pocket expenses will automatically be sent to the unit for processing. Reference plan #702682 on the form. |
| Health - TOP | |
| UnitedHealthCare Medical Claim Transmittal | Many medical providers will file claims electronically with UnitedHealthCare, whether they are participating providers or not. If your provider does not file directly, use this form to submit medical expenses for reimbursement. |
| Disabled Dependent Form for UnitedHealthCare | If you have a child who is eligible for coverage beyond age 19 due to mental retardation or a physical handicap, completion of this form will provide substantiation of the medical condition. |
| Prescription Drug Mail Order Form | Initial requests for ordering maintenance prescription drugs through the mail should be done on this form. Refills can also be ordered by accessing the website or by calling 1-800-4REFILL or 1-800-473-3455. |
| 2009 HMO Plan Enrollment/Change Form | Use this form to record the names of your covered dependents and their primary care physicians; or to add or delete dependents’ from coverage. Complete and return the form to MYHR at 585-338-0839. Note: Enrollment in the plan is NOT complete until this form is received by the HMO. |
| Pharmacy Reimbursement Form - for United Healthcare members only | This form serves two purposes. Use if you have paid 100% of the cost of your drugs and are seeking reimbursement for all but the copayment; or if you have more than one pharmacy plan and UHC's plan through Bausch & Lomb is the secondary coverage. Follow the instructions on the form for submitting your expenses. |
| MVP Health Dollars - Reimbursement Form | Use this form when seeking reimbursement for your Active Lifestyles or Family Focus Benefits. |
| Status Change - TOP | |
| Status Change Form - All Locations | As a result of a status change, this form is used to: - Add or delete dependants from coverage - Change level of coverage (single to family) - Enroll or drop coverage Complete the form, sign and fax to MYHR at 585.338.0839. |
| Evidence of Insurability Requirements for Additional Life and Disability Coverage | If you enroll in Life or Disability coverage within 30 days of your hire date, you are guaranteed to be accepted for coverage. If you enroll at any other time, including during annual enrollment periods, you may be required to submit Evidence of Insurability to Aetna and be approved before your enrollment can be processed. Contact My Benefits for additional information and to have the "Employer Statement" completed. |
| Other Benefits - TOP | |
| Lasik Surgery Reimbursement Form | Bausch & Lomb provides a LASIK benefit for eligible employees that have LASIK surgery performed with Bausch & Lomb lasers. Use this form to request reimbursement for up to $1,000 per eye for Lasik surgery. |
| Contact Lens Form | Any benefit eligible Bausch & Lomb employee, retiree, and/or dependent, as defined under the medical benefit plan, is eligible to receive an annual supply of Bausch & Lomb soft contact lenses as prescribed by their eye care practitioner. |
| Savings Bond Enrollment Form | Bausch & Lomb employees can invest in U.S. savings bonds, the benefits of this are listed below: Allows for purchases of U.S. savings bonds, Series EE in $100, $200, and $500, face value denominations; Series I in $50, $75, $100, $200, and $500 face value denominations. Minimum deductions as low as $10.00 per pay period; bond purchase price is half of face value for Series EE bonds; full face value for Series I bonds. Fax completed form to Payroll at 585/338-5917. |
| 2009 Brochure - Bright Start Make It A Bright One | College Savings Client Agreement If interested in enrolling your child(ren) in the Bright Start 529 College Savings Program, read the informational brochure, and complete an application and the client agreement. Send the application and client agreement to:
Morgan Stanley Smith Barney |
| Affadavit of Domestic Partnership | The Affidavit of Domestic Partnership form would be used if the domestic partner can be claimed as a tax dependent, so the employee is not taxed on the value of the benefits provided to the domestic partner. Bausch& Lomb does not require this form just to enroll a domestic partner. |
| Statement of Termination of Domestic Partnership | This form terminates the domestic partner so that the domestic partner can be removed from benefits as a mid-year change. It would also be important for someone to complete this form to notify Bausch & Lomb of the dissolution of the partnership if they ever wanted to enroll a new partner (because they can remove them from benefit programs at open enrollment and not indicate that the partnership has ended). |
