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)
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)

Fidelity 403(b) Beneficiary (PDF)
Fidelity 401(a) Beneficiary (PDF)
Fidelity 457(b) Beneficiary (PDF)
Fidelity 457(f) Beneficiary (PDF)
TIAA-CREF Beneficiary - ALL PLANS (PDF)

Tuition Benefits:

Tuition Benefits Application (PDF) (For dependents of retirees, university affiliates and dependents of deceased employees only.)
Faculty and Staff Certification of Graduate Tuition Benefits (PDF)
Research Personnel Certification of Graduate Tuition Benefits (PDF)

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.