Benefits Forms

Health Insurance

• Aetna Medical Claim Form
• Vision Claim Form

Dental Insurance

• Dental Claim Form

Voluntary Vision

• Vision Claim Form (for out of network providers)

Flexible Spending Accounts

• https://fba.wealthcareportal.com/Page/PublicDocuments

Life Insurance

• Evidence of Insurability Form
• Group Life Conversion Privilege Form

Supplemental Life Insurance

• Evidence of Insurability Form
• Group Term Life Insurance Portability Election Form
• Group Life Conversion Privilege Form

Time Off, Leaves and Disability

• FMLA Request
• Parental Leave Notification
• Workers' Compensation Treatment Acknowledgement 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