Human Resources

Available below for your convenience are links to downloadable forms related to medical benefits, disability, life insurance, domestic partner benefits, retirement, flexible spending accounts and general employment. (Please note: All forms are .pdf forms that require Adobe Reader.)

Forms Related to Domestic Partner Benefits
Forms Related to Life Insurance and Long Term Disability
Forms Related to Medical Benefits
Forms Related to Dental and Vision Plans
Forms Related to Retirement Planning
Forms Related to Section 125/Flexible Spending Accounts
Forms Related to Short Term Disability, FMLA, and/or Child-bearing Disability Leave
Forms Related to Workers’ Compensation
Payroll Forms
General Employment Forms
Forms Related to Performance Reviews

Forms Related to Domestic Partner Benefits

• Domestic Partner Benefits Policy
  (for policy details and definitions)
• Affidavit of Marriage or Domestic Partnership
  (to apply for domestic partner insurance coverage)
• Declaration of Dependent Tax Status
• IRS Worksheet for Dependent Tax Status
• Affidavit of Termination of Domestic Partnership
  (to cancel existing domestic partner coverage)

Forms Related to Life Insurance and Long Term Disability

• Life Insurance Certificate – Faculty
• Life Insurance Certificate – Nonfaculty Employees
• Long Term Disability Certificate – Faculty
• Long Term Disability Certificate – Nonfaculty Employees
• Beneficiary Designation Form
• Employee Assistance Program (EAP)

Forms Related to Medical Benefits

• Payroll Authorization Form – Current Employee
• HIGHMARK Blue Cross/Blue Shield Enrollment Application
  (to apply for medical insurance coverage)
• HIGHMARK Blue Cross/Blue Shield Member Change Form
  (to change members on your medical insurance coverage)
• Opt Out of Medical Coverage Form
  (available for those already covered by an existing medical plan)
• Highmark Benefit Book
• Summary of PPO Blue Benefits
• Summary Plan Description – Medical, Dental, Vision, Life/AD&D

Forms Related to Dental and Vision Plan

• Payroll Authorization Form – Current Employee
• Dental Plan Certificate of Insurance
• Dental Plan Benefits Summary
• Vision Plan Benefits Summary
• Dental Benefits Enrollment/Change Form
  (to apply, or to change a current application, for dental coverage under United Concordia)
• Vision Benefits of America Enrollment Form
  (to apply for vision insurance coverage)

Forms Related to Retirement Planning

• Summary Plan Description – Retirement Annuity (RA)
• Summary Plan Description – Supplemental Retirement Annuity (SRA)
• Enrollment Form for TIAA-CREF Retirement Annuity (RA) Contract
  (to enroll in a TIAA-CREF Retirement Annuity (RA))
• Enrollment Form for TIAA-CREF Group Supplemental Retirement Annuity (GSRA) Contract
  (to enroll in a TIAA-CREF Group Supplemental Retirement Annuity (GSRA))
• Designation of Beneficiary Form
  (to designate beneficiaries to a TIAA-CREF Retirement Annuity (RA) or Supplemental Retirement Annuity (SRA))
• Salary Reduction Agreement
  (to apply for, or to alter, a TIAA-CREF Retirement Equities Fund)

Forms Related to Section 125/Flexible Spending Accounts

• Summary Plan Description
• HIPAA Privacy Notice-FSA
• Health Care Flexible Spending Account Claim Reimbursement Form
  (for reimbursement of health care expenses)
• FSA Card Expense Substantiation Form
  (to prove eligibilty of purchases made using the FSA Card)
• Health Care Supporting Documentation: Proof of Medical Care Form
• Dependent Care Flexible Spending Account Claim Reimbursement Form
  (for reimbursement of dependent care expenses)
• Direct Deposit Enrollment/Authorization Form
  (for direct deposit of FSA reimbursements)
• FSA Card Secondary Card Request Form
• On-Line Forms Quick Reference Guide

Forms Related to Short Term Disability, FMLA, and/or Child-bearing Disability Leave

• FMLA Request Form
  (to apply for short-term disability leave or a leave of absence)
• Certification of Health Care Provider for FMLA Leave
• Initial Statement of Claim for Short-Term Disability Application
  (to apply for short-term disability leave or a leave of absence)
• Attending Physician’s Statement for Short-Term Disability Leave
  (to apply for short-term disability leave or a leave of absence)
• Authorization for Use in Obtaining Information for Short-Term Disability Leave
  (to apply for short-term disability leave or a leave of absence)

Forms Related to Workers’ Compensation

• Employee Injury Report Form
  (to report an accident)
• Panel of Providers
  (for a list of area providers)
• Notice of Rights and Duties
• Workers’ Compensation Information

Payroll Forms

• Biweekly Payroll Schedule
  (for non-exempt employees)
• Biweekly Payroll/Attendance Report
  (for non-exempt employees)
• Employee Authorization for Direct Payroll Deposit
  (to request direct deposit)
• W-4 Form
  (for federal income tax purposes. You may fill-in the W-4 form and print)
• I-9 Form
• Local Services Tax Exemption Certificate
  (to apply for LST exemption)
• Summer/Winter Non-Allegheny Student Employment Form
• Summer/Winter Non-Allegheny Student Timesheet
• Local Earned Income Tax Residency Certification Form
• Act 32 PSD Codes
• Electronic Timesheet Instructions

General Employment Forms

• Employee Data Update Form
  (to inform Human Resources of a change in campus or personal information)
• Employee Family ID Request

Forms Related to Performance Reviews
In Microsoft Word format

• Annual Review Form – Exempt Administrative Staff
• Instructional Memo – Exempt Administrative Staff
• Annual Review Form – Nonexempt Office/Support Staff
• Annual Review Form – Nonexempt Service/Maintenance Staff
• Instructional Memo – Nonexempt Staff