| Adoption Request Form |
Request adoption assistance reimbursement for certain costs that may be incurred during the adoption process |
| Blue Cross Health Insurance Claim Form |
Request reimbursement for applicable medical expenses incurred for services not directly billed to the plan |
| BlueCard Worldwide International Claim Form |
Request reimbursement for applicable medical expenses incurred for services during an international travel |
| Blue Cross Dental Insurance Claim Form |
Request reimbursement for applicable dental expenses for services not directly billed to the plan |
| Declaration of Tax Status Form |
Form to declare the tax status of a dependent child or Second Domiciled Adult (SDA) |
| Dependent Add/Change Form |
Request to add or update dependent information |
| HSA Contribution Election Change Form |
Request to add or update Health Savings Account contribution |
| Manual Tuition Waiver Form |
Request tuition waiver for retirees, dependents of retiree, employees with special arrangements or Unrelated SDA |
| Part-Time Faculty Tuition Waiver Form |
Request tuition waiver for Part time Faculty |
| Personal Leave of Absence Request Form |
Request for Personal Leave of Absence |
| Prescription Reimbursement Claim Form |
Claim form to request prescription reimbursement |
| Express Scripts (ESI) Mail Order Prescription Form |
Request for prescription to be sent via mail |
| SDA Affidavit Form |
Request to add a Second Domiciled Adult (SDA) during new hire open enrollment or annual enrollment |
| Tuition Waiver Proof of Dependency Affidavit |
Affidavit form for dependents requesting tuition waiver |
| SDA Tuition Waiver Affidavit |
Affidavit for Unrelated Second Domiciled Adult requesting a tuition waiver |
| Voluntary Unpaid Time-Off Request Form |
Request for voluntary unpaid time off |
| Teleworking Agreement Form |
Agreement between manager and employee of teleworking arrangement |
| V-Time Form |
Request for voluntary flex schedule |
| Return from V-Time Form |
Request to return to normal employment from a voluntary flex schedule |
| HealthEquity/WageWorks Parking and Transportation Claim Form |
Request reimbursement for eligible parking and transportation expenses with pre-tax dollars |
| HealthEquity/WageWorks Dependent Care FSA Claim Form |
Request reimbursement for eligible day care expenses with pre-tax dollars |
| HealthEquity/WageWorks Healthcare FSA Claim Form |
Request reimbursement for eligible health care expenses with pre-tax dollars |