Benefit Forms

Employment Forms

Medical:

Premera Medical Expense Claim Form

Premera Prescription (Rx) Claim Form

Premera Medco by Mail Order Form

Premera Community Wellness Reimbursement Form

Health Insurance Waiver Form

Read carefully prior to completion and submission to HR

Dental:

WDS Dental Claim Form

Vision:

VSP Vision Claim Form
Must contact VSP prior to use: 1-800-877-7195

Flexible Spending Accounts (FSAs): For health and dependent care expenses FSA's are administered by Benefit Administration Company (BAC)

Forms may be printed or filled-in online

BAC Healthcare Reimbursement Form - revised

BAC Dependent CareReimbursement Form - revised

BAC Benefits Card Enrollment Form

BAC Reimbursement Direct Deposit Authorization

List of Allowable Healthcare Expenses and Over the Counter Items

Long Term Care Insurance:

Long Term Care - Evidence of Insurability

Additional Life and AD&D Insurance:

Additional Life Insurance/AD&D: Enrollment and Change Form (also allows you to designate or change beneficiaries)

Medical History Statement

Termination or Reduction of Insurance Form

SPU Staff Application

Online Application through InterviewExchange

 

Adjunct Application

 

Old Exempt Application

 

Hiring Process Timeline

 

Position Management

• Job Description- Form
• Job Description-Sample

• Position Revision Proposal Form

 

Recruiting Process

• Link to INTERVIEW EXCHANGE:  Recruiting Requisitions and to Manage Posted Positions

• Supplemental Screening Question Samples

 

New Employee Process

• I-9 Form 

• I-9 Remote Hire Notary Form

• PAF - Regular Employee
• PAF - Temp  Employee

Retirement Savings Forms

Performance Evaluation Forms

Other Forms

 

403(b) contribution changes may now be made online with Diversified at www.divinvest.com

 

Performance Evaluation Form

Business & Planning Employee Evaluation Form

Business & Planning Peer Evaluation Form

 

Employee Information Change Form (formerly Name/Address Change Form)

Leave of Absence (LOA) Request