Benefits Forms

Health Insurance

• 2020-21 Benefits Enrollment Form
• Aetna Enrollment/Change Request Form
• Vision Claim Form

Dental Insurance

• Dental Insurance Enrollment / Status Change / Claim Form

Voluntary Vision

• Vision Claim Form (for out of network providers)

Flexible Spending Accounts

• FSA Enrollment Form
• For all other forms go to http://www.flex-admin.com/participants/forms/

Life Insurance

• Basic Life Insurance Beneficiary Designation Form
• Please contact HR if you need a form that is not listed

Supplemental Life Insurance

• Please contact HR if you need a form that is not listed

Retirement Savings Plan

• Defined Contribution Plan Participation Authorization and Salary Reduction Agreement Form
• Certificate for Hardship Withdrawal
• Prior Hours Verification Form

Time Off, Leaves and Disability

• Leave Notification for Exempt Employees
• FMLA Request
• Parental Leave Notification
• Workers' Compensation Treatment Acknowledgement Form
• Group Long Term Disability Tax Election Form- 7/1/2019
• Group Long Term Disability Tax Election Form (effective 7/1/2020)

Work/Life

• Dual Career Intake
• Faculty Meeting Childcare
• Emergency Back-Up Care Reimbursement
• Weight Watchers Payment Agreement

Domestic Partner Benefits

• Declaration of Domestic Partnership
• Declaration of Tax Dependent Status
• Declaration of Termination of Domestic Partnership