Benefits Forms
Accident Reporting Form (for Workers' Compensation): This form is used to report accidents that occur on campus property.
Alternate-Reduced Work Arrangement: This form is used by employees and supervisors to create an agreement and to describe a work schedule that will vary from the employee's typical work week. This could be on a long-term or short-term basis.
Dental Claim: This form is used to submit dental claims to the provider.
Disability Reporting: This form is for employees and supervisors to report a non-work–related disability.
Domestic Partnership Forms
Domestic Partner Affidavit: This form is used to add and verify a domestic partner if you are selecting domestic partner coverage.
Domestic Partner Dependent Children Eligibility Certification: This form is used to enroll a domestic partner's qualified dependent children, if you selected domestic partner coverage.
Domestic Partner Termination: This form is used to remove a domestic partner, if you selected domestic partner coverage
External Tuition Grant Application: This form is used by ºÚÁϳԹÏÍø employees to apply for the External Tuition Grant for their legally dependent children attending a college other than ºÚÁϳԹÏÍø.
Faculty Parental Leave Request:This form is used by ºÚÁϳԹÏÍø faculty to apply for parental leave.
FMLA Forms: Please reach out to HR to request FMLA forms.
Flexible Spending Account Forms: These forms are used by employees to request reimbursement from their Flexible Spending Accounts (Health Care Spending and Dependent Care Spending) for services incurred.
Internal Tuition Grant Application: This form is used for employees who wish to apply for the internal tuition benefit.
Life Insurance Forms
This form is used by employees during open enrollment who wish to enroll in dependent life insurance or supplemental life insurance or increase their current supplemental life insurance.
MVP Forms
Alternative Health Benefit Reimbursement form: This form is to be used for direct reimbursement from MVP for any service under Alternative Health Benefits: acupuncture; fitness center membership; homeopathic care; hypnotherapy for weight control or smoking cessation; massage therapy; and nutritional counseling.
Authorization to Disclose Information: This form is used to give MVP permission to share health information with a third party.
Medical Claim Reimbursement: This form is used to request reimbursement for any medical expense.
Prescription Plan Forms
Optum Mail Order: This form should be used by employees and their dependents who are participants in the ºÚÁϳԹÏÍø PPO or EPO plans to fill their prescription coverage through mail order. Mail order prescriptions are for a 90-day supply with the copay equivalent to 2.5 retail copays, saving a half month's copay.
Optum Direct Reimbursement Claim: This form should be used by employees or their dependents who are participants in the ºÚÁϳԹÏÍø PPO, EPO, or HDHP plan for reimbursement of any eligible prescription drug costs paid in full out of pocket.
