Benefits Forms

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• Affidavit of Domestic Partnership/Acknowledgment of Domestic Partnership
• Flu Vaccination Consent Form
• Supplemental Life Evidence of Insurability
• Life Beneficiary Designation

Benelect Forms

• Benelect 2013 Enrollment Form
• Benelect 2013 Change of Status
• Working Spouse Premium Election Form
• Health Savings Account Contribution Change Form
• 2013 Benelect cost structure for full-time employees 100% Faculty and Staff Price Sheet
• 2013 Benelect cost structure for three-quarter-time (nonexempt working 28-37.4 hr/wk, exempt working 30-39.9 hr/wk) 75% Faculty and Staff Price Sheet
• 2013 Benelect cost structure for half-time (nonexempt working 18.75-27.9 hr/wk, exempt working 20-29.9 hr/wk) 50% Faculty and Staff Price Sheet

Education

• Certification for Tuition Waiver
• Affidavit of Qualification for Tuition Waiver Tax Exemption
• Child's Proof of Dependency Affidavit
• Certification for Tuition Reimbursement #HR20050101
• Tuition Exchange Program Eligibility Certification

Insurance Claims

• Dentemax Claim Form
• Flexible Spending Account Reimbursement Claim Form (Health and Dependent Care)
• Medical Mutual of Ohio (MMO) Claim Form
• VSP Out-of-Network Reimbursement Form
• Union Eye Care Reimbursement Form

Leave of Absence

• Leave of Absence Form
• Personal Medical Certificate of Health Care Provider
• Family Medical Certificate of Health Care Provider
• Servicemember Family Medical Certificate of Health Care Provider
• Certification of Qualifying Exigency
• Certification By a Health Care Provider for Returning to Work

Retirement

• Retirement Plan B Beneficiary Designation
• Salary Reduction Agreement and Investment Election Form (Plan A)
• Salary Reduction Agreement and Investment Election Form (Plan C)
• 457b Deferred Compensation Change Form

Payroll

• Vacation Day Purchase Request Form
• Please refer to Policy no. IV-6 for information regarding the Vacation Buy Program

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