Forms

MANAGERS: Need forms related to hiring, performance management, attendance or termination? Visit the Manager Toolkit Forms page.

BENEFITS FORMS

• Flexible Spending Accounts (FSAs)
• Flexible Work Arrangement Proposal Form
• Transit/Parking Reimbursement Program (T/PRP)
• Dental
• Healthcare
• Aetna
• CIGNA
• HIP
• UnitedHealthcare
• Prescriptions
• Life Insurance
• Long-Term Disability Insurance
• Tuition
• Post-Doctoral Fellows
• Adoption
• HIPAA

DISABILITY AND WORKERS' COMPENSATION FORMS

VOLUNTARY SELF-IDENTIFICATION FORMS

Benefits Forms

Flexible Spending Accounts (FSAs)

• FSA Reimbursement Request Form (PDF/Word)
• FSA Direct Deposit Form (PDF)

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Flexible Work Arrangement Proposal Form

•  Flexible Work Arrangement Proposal Form (Word)

• Parking Payroll Deduction Authorization (PDF/Word)
• T/PRP Reimbursement Form (PDF/Word)

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Dental

• Aetna Columbia Dental Plan Claim Form (PDF)
• GHI Claim Form (PDF)

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Healthcare

• Aetna
  • Aetna Medical Claim Form (PDF)
  • Aetna Vision Claim Form (PDF)
• CIGNA
  • CIGNA Behavioral Care Out of Network Claim Form (PDF)
  • CIGNA Medical Claim Form (PDF)
  • CIGNA PCP Selection Form (Word)
  • CIGNA Student Verification Form (PDF)
• HIP
  • HIP Subscriber/Member Enrollment Form (PDF)
• UnitedHealthcare
  • UnitedHealthcare Medical Claim Form (PDF)

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Prescriptions

• MEDCO Prescription Drug Claim Form (PDF)
• MEDCO Prescription Drug Mail Order Form (PDF)

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Life Insurance

• The Standard: Beneficiary Designation Form (PDF)
• The Standard: Evidence of Insurability for CT Residents (PDF)
• The Standard: Evidence of Insurability for NJ Residents (PDF)
• The Standard: Evidence of Insurability for NY Residents (PDF)

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Long-Term Disability Insurance

• CIGNA Group Insurance LTD Evidence of Insurability Form (PDF)

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Tuition

• Print your Tuition Exemption Eligibility Form from the CU Online Benefits Enrollment System
• College Tuition Scholarship (CTS) Form (PDF/Word)
• Primary Tuition Scholarship (PTS) Application Form (PDF/Word)
• Job Related Graduate Course Certification Application Form (PDF/Word)
• 2110/CU Tuition Assistance Application (PDF/Word)

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Post-Doctoral Fellows

• Post-Doctoral Medical Benefits Enrollment Form (PDF/Word)

Adoption

• Adoption Assistance Form (PDF/Word)

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HIPAA

• HIPAA Privacy Authorization Form (PDF/Word)

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Disability and Workers' Compensation Forms

• Department Accident Report (PDF)
• Disability Release (PDF)
• NY State Disability Form DB 450 (PDF)
• Request for Reasonable Accommodation (PDF)

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Voluntary Self-Identification Forms

• Voluntary Self-Identification: Disability (Word) 
• Voluntary Self-Identification: Veteran (Word)

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