Benefits Forms

Medical Insurance:

UHC Medical Claim (PDF)
UHC Medical Claim - International Claims (PDF)

Prescription Drug Program:

Caremark Prescription Claim (PDF)
Caremark Prescription Mail Order (PDF)
International Prescription Claim Form (PDF)

Dental Insurance:

Aetna Dental Claim (PDF)

Vision Insurance:

Out-of-Network Claim (PDF)

Flexible Spending Accounts (FSAs):

PayFlex Claim (PDF)
FSA Claim Filing Guidelines (PDF)
Letter of Medical Necessity - HCFSA only (PDF)

Health Savings Account (HSA):

PayFlex Trustee Transfer (PDF)

Life Insurance:

Beneficiary Designation (PDF)

Long-Term Disability (LTD):

LTD Prior Coverage Verification (PDF)

Leave of Absence:

Reporting Your Claim or Leave (PDF)
Personal Leave Request (PDF)
Authorization to Return to Work (PDF)


401(a) Prior Employment Verification Form (PDF)
457(b) Fidelity Enrollment Guide and Enrollment Form (PDF)
457(b) TIAA Enrollment Guide and Enrollment Form (PDF)
2020 457(b) Salary Reduction Agreement (PDF)

Tuition Benefits:

Tuition Benefits Application (PDF) (For dependents of retirees, university affiliates and dependents of deceased employees only.)
Graduate Course Certification Online Form for Tax Exemption - GW Employee Only


Declaration of Common Law Marriage (PDF)
Declaration of Domestic Partnership (PDF)
Dissolution of Domestic Partnership (PDF)
Declaration of Civil Union (PDF)

HIPAA Authorization:

GW Authorization for the Release of Protected Health Information (PDF)
Benefits Call Center – PHI Release (PDF)

Pre-Tax Transportation Program:

Payroll Services manages the pre-tax transportation program and can provide you with necessary information for enrollment.