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 and/or Supplemental Life Insurance Enrollment Form for Initial or Mid-Year Enrollment
• Basic Life Insurance Beneficiary Designation Form
• Evidence of Insurability Form
• Group Life Insurance Form

Supplemental Life Insurance

• Basic and/or Supplemental Life Insurance Enrollment Form for Initial or Mid-Year Enrollmen
• Evidence of Insurability Form
• Group Life Insurance Form
• Group Term Life Insurance Portability Election Form
• Supplemental Life Beneficiary Designation Form

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 

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