Benefits - View and Print Forms:

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Checklist for New Employees

• New Employee Benefits Checklist

Medical, Dental, Life, Flexible Spending Enrollment/Changes

• Benefits Enrollment/Changes Form
• PHI Release for Claims Resolution

Spouse/Domestic Partner

• Spouse/Domestic Partner Affidavit & Memo
• Termination of Domestic Partnership

Flexible Spending Account Claim Forms

• Health Care Spending Claim Form
• Dependent Care Spending Claim Form

Voluntary Life, ADD, and LTD Insurance

• Voluntary Life, ADD, and LTD Insurance Form

Long Term Care Insurance

• Employee - Enrollment Form
• Family- Enrollment Form

Retirement

• TIAA-CREF Retirement Plan Contribution Form
• Sample GRA Eligiblity Waiver Letter

Tuition

• Application for Tuition Remission
• Preliminary Application for National Tuition Exchange
• Tuition Exchange Recertification Application
• Tuition Reimbursement Form

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Family/Medical Leaves

Step 1

General Information About Family/Medical Leaves
What you should know about Family Medical Leaves.

Family Leave Policy (FMLA/OFLA)
For more detailed information please see our policy.

Step 2

Family/Medical Leave Request Form
To take your protected leave, you must submit your request.

Step 3

Certification from a Health Care Provider For:

Employee's Serious Health Condition
Please have a Health Care Provider complete if you are taking time off for your own condition.

Family Member's Serious Health Condition
Please have a Health Care Provider complete if you are taking time off to care for your family member.

Serious Illness or Injury of Covered Service Member
Please have a Health Care Provider complete if you are taking time off to care for a servicemember.

Certification of Qualifying Exigency For:

Military Family Leave
Please complete if you need to take time off for active duty or if you need to help a family member prepare for active duty.

Step 4

PHI Release of Own Health Info Form
You must authorize the disclosure of your protected health information.

PHI Release of Dependent's Health Info Form
Your dependent must authorize the disclosure of their protected health information.

Step 5

Fitness for Duty Form
Please have your Health Care Provider complete at the end of your own serious health condition leave to ensure you are physically ready to return to work.