Benefits Forms

Medical Insurance:

UHC Medical Claim (PDF)
UHC Medical Claim - International Claims (PDF)
Requirements for Submitting Non-Network Medical Claims (PDF) 
Extended Network/Continuation of Care (PDF)

Prescription Drug Program:

Caremark Prescription Claim (PDF)

Caremark Prescription Mail Order (PDF)

International Prescription Claim Form (PDF)

Dental Insurance:

Aetna Dental Claim Form (PDF)

Flexible Spending Accounts:

PayFlex Claim (PDF)

FSA Claim Filing Guidelines
Letter of Medical Necessity (HC-FSA only)
PayFlex Trustee Transfer Form

Life Insurance:

Beneficiary Designation (PDF)
Beneficiary Designation (PDF) New York Residents ONLY
Group Life Portability and Conversion Notice (PDF)

Vision Benefits:

Out of Network Claim (PDF)
Vision Benefits Online Information, through United Healthcare (myuhc.com)

Long Term Disability:

LTD Year Waiver (PDF)

Leave of Absence:

Reporting Absences and Filing a Disability Claim (PDF)
Personal Leave Request (PDF)
Authorization to Return to Work (PDF)

Retirement:

401(a) Prior Employment Verification Form (PDF)
457(b) Fidelity Enrollment Guide and Enrollment Form (PDF)
457(b) TIAA-CREF Enrollment Guide and Enrollment Form (PDF)

457(b) Salary Reduction Agreement 2017 (PDF)
457(b) Salary Reduction Agreement 2018 (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

Declarations:

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.