Staff Benefits Forms
All forms are PDF 
format, unless otherwise noted,
download the free reader
- Affidavit for Same-Sex Domestic Partner coverage
- Dissolution of Same-Sex Domestic Partnership
- Fee Waiver - Staff/Faculty
- Fee Waiver - Spouse
- Fee Waiver - Child
- Application for Health, Dental and Prescription Drug Card Coverage
- Medical Claim Form (if provider does not file claim for you)
- Delta Dental Claim Form
- Enrollment form for UnitedHealthCare Vision (Vision Coverage)
- Vision Coverage Out-of-Network Claim Form
- MEDCO Prescription Claim Form
- MEDCO Prescription Mail Order Form
- MEDCO Order Form for Doctor
- Flexible Spending Account Application
- List of Documentation for I9 (Employment Eligibility Verification) Form
- Voluntary Sick Leave Donation Agreement Form
- Sick Leave Transfer Medical Form
- Phased Retirement Application
- Salary Reduction Form ( under section 403(b) or 457(b))
- CIGNA FSA Reimbursement Form 2010 (Medical)
- CIGNA FSA Dependent Care Reimbursement Form 2010
- CIGNA Medication Prior Authorization Form - Specialty Drugs
- Tax Deferred Annuity Agreement Form
- Voluntary Contributions to PERF ASA
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