Forms « Human Resources | Allegheny College

Forms

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

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

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, 2019
Summary of QHDHP Benefits – July 1, 2019
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, 2019
Medical Rates – QHDHP – July 1, 2019
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 Plan Benefits Summary – Buy Up Plan
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 – 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

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
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:

Exempt: