Allegheny College: Human Resources

Forms

Available below for your convenience are links to downloadable forms related to medical benefits, disability, life insurance, domestic partner benefits, retirement, flexible spending accounts and general employment. (Please note: All forms are .pdf forms that require Adobe Reader.)

Forms Related to Domestic Partner Benefits

Domestic Partner Benefits Policy
(for policy details and definitions)
Affidavit of Marriage or Domestic Partnership
(to apply for domestic partner insurance coverage)
Declaration of Dependent Tax Status
IRS Worksheet for Dependent Tax Status
Affidavit of Termination of Domestic Partnership
(to cancel existing domestic partner coverage)

Forms Related to Life Insurance and Long Term Disability

Forms Related to Medical Benefits

Payroll Authorization Form - Current Employee
HIGHMARK Blue Cross/Blue Shield Enrollment Application
(to apply for medial insurance coverage)
HIGHMARK Blue Cross/Blue Shield Member Change Form
(to change members on your medical insurance coverage)
Opt Out of Medical Coverage Form
(available for those already covered by an existing medical plan)
Highmark Benefit Book

Forms Related to Dental and Vision Plan

Payroll Authorization Form - Current Employee
Dental Plan Certificate of Insurance
Dental Plan Benefits Summary
Vision Plan Benefits Summary
Dental Benefits Enrollment/Change Form
(to apply, or to change a current application, for dental coverage under United Concordia)
Vision Benefits of America Enrollment Form
(to apply for vision insurance coverage)

Forms Related to Retirement Planning

Summary Plan Description - Retirement Annuity (RA)
Summary Plan Description - Supplemental Retirement Annuity (SRA)
Enrollment Form for TIAA-CREF Retirement Annuity (RA) Contract
(to enroll in a TIAA-CREF Retirement Annuity (RA))
Enrollment Form for TIAA-CREF Group Supplemental Retirement Annuity (GSRA) Contract
(to enroll in a TIAA-CREF Group Supplemental Retirement Annuity (GSRA))
Designation of Beneficiary Form
(to designate beneficiaries to a TIAA-CREF Retirement Annuity (RA) or Supplemental Retirement Annuity (SRA))
Salary Reduction Agreement
(to apply for, or to alter, a TIAA-CREF Retirement Equities Fund)

Forms Related to Section 125/Flexible Spending Accounts

Summary Plan Description
HIPAA Privacy Notice-FSA
Health Care Flexible Spending Account Claim Reimbursement Form
(for reimbursement of health care expenses)
FSA Card Expense Substantiation Form
(to prove eligibilty of purchases made using the FSA Card)
Dependent Care Flexible Spending Account Claim Reimbursement Form
(for reimbursement of dependent care expenses)
Direct Deposit Enrollment/Authorization Form
(for direct deposit of FSA reimbursements)

Forms Related to Short Term Disability Leave or Child-bearing Disability Leave

FMLA Request Form
(to apply for short-term disability leave or a leave of absence)
Initial Statement of Claim
(to apply for short-term disability leave or a leave of absence)
Attending Physician's Statement
(to apply for short-term disability leave or a leave of absence)
Authorization for Use in Obtaining Information
(to apply for short-term disability leave or a leave of absence)

Forms Related to Workers' Compensation

Employee Injury Report Form
(to report an accident)
Panel of Providers
(for a list of area providers)
Notice of Rights and Duties
Workers' Compensation Information

General Employment Forms

Biweekly Payroll Schedule
(for non-exempt employees)
Biweekly Payroll/Attendance Report
(for non-exempt employees)
Employee Authorization for Direct Payroll Deposit
(to request direct deposit)
Name and Address Update Form
(to inform Human Resources of a change in name or address)
W-4 Form
(for federal income tax purposes. You may fill-in the w-4 form and print)
Statement of Domicile
(to report a change in your domicile)
EMS Refund Request Form 2007
Meadville EMS Tax Refund
Local Services Tax Exemption Certificate
(to apply for LST exemption)

Forms Related to Performance Reviews
In Microsoft Word format