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 – Non-faculty Employees
• Supplemental Term Life Insurance Overview
• Supplemental Term Life Insurance Enrollment Form
• Grief Counseling Information
• Will Preparation FAQ
• Travel Assist
• Long Term Disability Certificate – Faculty
• Long Term Disability Certificate – Non-faculty Employees
• Beneficiary Designation Form

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)
• Summary of PPO Blue Benefits – July 1, 2018
• Summary of QHDHP Benefits – July 1, 2018
• National Plus Pharmacy Network
• Affidavit for Spousal Coverage
• HSA Eligible Expenses
• HSA Ineligible Expenses
• HSA Election Form
• Medical Plan Cost Calculator
• Medical Rates – PPO – July 1, 2018
• Medical Rates – QHDHP – July 1, 2018
• Virtual Doctor’s Visit
• Summary Plan Description – Health & Welfare Plan

Forms Related to Dental and Vision Plan

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

Forms Related to Retirement Planning

• Summary Plan Description – Retirement Annuity (RA)
• Other Plan Information – Retirement Annuity (RA)
• Summary Plan Description – Supplemental Retirement Annuity (SRA)
• Summary of Material Modifications – 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))
• Verification of Employment for Participation in Retirement Annuity (RA)
• 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 – Section 125 Plan
• 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 eligibility 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 Information (for direct deposit of FSA reimbursements)
• FSA Card Secondary Card Request Form
• On-Line Claim Submission Guide (debit cards)
• On-Line Claim Submission Guide (non-debit cards)
• FSA Eligible Expenses

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
• I-9 Instructions
• Local Services Tax Exemption Certificate (to apply for LST exemption)
• Summer/Break Non-Allegheny Student Employment Form
• Summer/Break 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
• Background Check Authorization Form
• Mentor Program Participation Form
• Administrator (exempt) Vacation/Personal/Sick Tracking Form

Forms Related to Performance Reviews

Nonexempt:

•  Nonexempt Performance Review Instructions
•  Nonexempt Office/Support Staff Annual Review Form
•  Nonexempt Office/Support Staff Supervisor Form
•  Nonexempt Service/Maintenance Annual Review Form
•  Nonexempt Service/Maintenance Supervisor Form
• Job Description – Nonexempt

Exempt:

• Exempt Performance Review Instructions
• Exempt Performance Review Supervisor Form
• Exempt Performance Review Employee Form
• Job Description – Exempt