Benefits Forms

Enrollment Forms

Benefits Change Form

Retirement Change Form

1 Year Service Waiver

Life Insurance Evidence of Insurability

Dependent Care FSA Employer Match Application

Same-Gender Domestic Partner Relationship Declaration

Same-Gender Domestic Partner Relationship Termination

Mail Order Prescription Forms

Walgreens Health Initiatives Mail Order (PPO)

Walgreens Health Initiatives Mail Order (HMOIL)

Prime Therapeutics Mail Order

Unicare Mail Order

Long Term Care Applications

New Hire Long Term Care Application

Faculty and Staff Long Term Care Application

Spouse/Domestic Partner Long Term Care Application

Retiree Long Term Care Application

Claim Forms

BlueCross BlueShield Health Claim Form

BlueCross BlueShield Dental Claim Form

Walgreens Health Initiatives Claim Form

Prime Therapeutics Claim Form

PayFlex FSA Claim Form

Leave of Absence Forms

Short Term Disability Evidence of Good Health

Long Term Disability Evidence of Good Health

Leave of Absence Request

Short Term/Long Term Disability Claim Form

Certification of Health Care Provider

Staff Leave of Absence Provisions and Application Forms

Forms for Separating Employees

Retiree Wildcard Privileges

Retiree Health Insurance Enrollment Form

Retiree Dental Insurance Enrollment Form

Retiree Vision Insurance Enrollment Form

COBRA Health Insurance Enrollment Form

COBRA Dental Insurance Enrollment Form

COBRA Vision Insurance Enrollment Form

Automatic Withdrawal of Insurance Premiums