Employee Benefits Forms
Below are links to some of our most requested benefits forms. If there is a form you need that is not listed here, contact the Office of Human Resources.
ALTERNATIVE RETIREMENT PLAN FORMS
LONG-TERM DISABILITY INSURANCE FORMS
DEFERRED COMPENSATION PLAN FORMS
FAMILY AND MEDICAL LEAVE ACT FORMS
- HIPAA Form 11-3-2015
- AFSCME-SPFPA (SPF) Employee Serious Health ConditionCertification Form
- AFSCME-SPFPA (SPF) Family Member Serious Health Condition Certification Form
- FMLA Employee Serious Health Condition Certification Form
- FMLA Family Member Serious Health Condition Certification Form
- AFSCME-SPFPA (SPF) Absence Request Form
- Coaches Request Form for FMLA
- Faculty Request Form for FMLA
- Manager (Non-Represented) Absence Request Form
- OPEIU Absence Request Form
- SCUPA Absence Request Form
FLEXIBLE SPENDING ACCOUNT FORMS
- FSA Claim Form - Information is pre-populated. Employee will nee their user id and password for ADP.
- FSA Enrollment Change Form
HEALTH INSURANCE FORMS FOR FACULTY, MANAGERS, NURSES, COACHES AND POLICE OFFICERS
HEALTH INSURANCE FORMS FOR AFSCME AND SCUPA
GROUP LIFE INSURANCE FORMS
TAX-SHELTERED ANNUITY – RETIREMENT@WORK
TUITION WAIVER FORMS
FACULTY HEALTH AND WELFARE FUND
- Faculty Dental and Vision information may be found at PAFAC website.
LIFE AND ACCIDENT INSURANCE
EMPOWER RETIREMENT, THE RETIREMENT BUSINESS OF GREAT-WEST FINANCIALS
- Visit Empower Retirement's website to access current forms.