Forms

Forms for New Hires [+]

Foreign National Payment Procedures [+]

Benefits Forms and Documents [+]

How Benefits Are Affected When Employment Terminates
Status of Your Benefits Upon Termination - Full-time Faculty and Administrative Staff (PDF)   2014 COBRA Rates - Full-time Faculty and Administrative Staff Plans (PDF)
Status of Your Benefits Upon Termination - Part-time Faculty (PDF)   2014 COBRA Rates - Part-time Faculty Plans (PDF)
Statement of Domestic Partnership
Statement of Domestic Partnership (PDF)  
Dental Care Plans (Delta Dental)
PPO Plan Reimbursement Claim Form (PDF)
 
Enrollment/Change Form - Full-Time Faculty and Administrative Staff (PDF)   
Enrollment/Change Form - Part-Time Faculty (PDF)
 
Flexible Spending Accounts (EBPA)
Dependent Care Claim Form (PDF)   Direct Deposit Form (PDF)
Health Care Claim Form (PDF)   Additional Benefits Card Request Form (PDF)
Health Care Plan
Health Care Enrollment/Change Form for Full-Time Faculty and Administrative Staff (PDF)   Health Care Enrollment/Change Form for Part-Time Faculty (PDF)

UnitedHealthcare Reimbursement Claim Form (PDF)
Policy # 752051
Address: P.O. Box 740800, Atlanta, GA 30374
 
UnitedHealthcare Reimbursement Claim Form For Mental Health Services Only  (PDF)

Submit a Non-Network Mental Health Claim Electronically (PDF)
Health Saving Account Application (PDF) (available only if enrolled in the High Deductible Health Plan)   Health Saving Account - Employee Contribution Form (PDF) (available only if enrolled in the High Deductible Health Plan)
UnitedHealthcare Vision Plan
Contact Lens Formulary List (In-network benefits) (PDF)
UnitedHealthcare Vision Out-of-Network Reimbursement Claim Form (PDF)
Prescription Drug Coverage
Optum Rx Prescription Home Delivery Mail Order Form (PDF)
   
Life Insurance Plan (The Standard Life Insurance Company of NY)
Life Insurance Beneficiary Designation Form (PDF)    
Long Term Care Information
Long Term Planning Associates, LLC (PDF)    
Qualified Transportation Expenses (QTE) Plan (EBPA)
Enrollment/Change Form (PDF)   Direct Deposit Form (PDF)
Reimbursement Claim Form (PDF)    
Retirement - Tax-Deferred Annuity (TDA) Plan (TIAA-CREF)
Salary Reduction Agreement Form (PDF)    
Tuition Waiver Application
 (PDF)   Tuition Waiver Application for Part-Time Faculty - Summer 2014 semester (PDF)

Career Development Program [+]

Performance Appraisals [+]

Administrative Staff and Union Employees
Self-evaluation Form (DOC)  
Supervisor Evaluation Form (DOC) (for use by Supervisors)
Evaluation Form Follow-Up (DOC)   Evaluation Form Follow-Up (for use by Employees)
Senior and Executive Staff
Self-evaluation Form (DOC)
(Senior and Executive Staff)
  Supervisor Evaluation Form (DOC)
(Senior and Executive Staff)
 
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