Available below for your convenience is information and/or links to downloadable forms related to medical benefits, disability, life insurance, domestic partner benefits, retirement, flexible spending accounts and general employment.
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
Information Related to Medical Benefits
- National Plus Pharmacy Network
- HSA Eligible Expenses
- HSA Ineligible Expenses
- Medical Plan Cost Calculator
- Virtual Doctor’s Visit
Information Related to Dental and Vision Plan
- Dental Plan Certificate of Insurance
- Dental Plan (Buy-Up) Certificate of Insurance
- Dental Plan Benefits Summary
- Dental Plan Benefits Summary – Buy Up Plan
- Vision Plan Instructions
- Vision Plan FAQ
- Vision Plan Benefits Summary
Information Related to Retirement Planning
- Summary Plan Description – Defined Contribution Plan (Retirement Choice – RC)
- Verification of Employment for Participation in Retirement Annuity (RA)
- Salary Reduction Agreement (to apply for, or to alter retirement deductions)
- Retirement Plan Enhancements
Forms Related to Section 125/Flexible Spending Accounts
- HIPAA Privacy Notice-FSA
- FSA Cheat Sheet P&A Group (effective 7/1/20)
- How to Log into your Account P&A Group (effective 7/1/20)
- FSA Eligible Expenses P&A Group (effective 7/1/20)
- Panda Mobile App P&A Group (effective 7/1/20)
- Health Care Flexible Spending Account Claim Reimbursement Form (for Wage Works through 6/30/20)
- FSA Card Expense Substantiation Form (for Wage Works through 6/30/20)
- Health Care Supporting Documentation: Proof of Medical Care Form (for Wage Works through 6/30/20)
- Dependent Care Flexible Spending Account Claim Reimbursement Form (for Wage Works through 6/30/20)
- Direct Deposit Enrollment Information (for Wage Works through 6/30/20)
- FSA Card Secondary Card Request Form (for Wage Works through 6/30/20)
- FSA Eligible Expenses(for Wage Works through 6/30/20)
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
Information Related to Payroll
- Biweekly Payroll Schedule (for non-exempt employees)
- Biweekly Payroll/Attendance Report (for non-exempt employees)
- Local Services Tax Exemption Certificate (to apply for LST exemption)
- Summer/Break Non-Allegheny Student Employment Form
- Summer/Break Non-Allegheny Student Timesheet
- Electronic Timesheet Instructions
- Employee Family ID Request
- 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