Benefit Forms

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TypeFormDownload
HealthBenefits Guide Book 2017Online
HealthDirect Pay Health Benefits Enrollment Form
HealthContractual Health Benefits Enrollment Form
HealthDisabled Dependent Certification
HealthHealth Insurance Portability & Accountability Act (HIPAA)
HealthRegular Status Health Benefits Enrollment Form
HealthRetiree Health Benefits Enrollment
HealthDecline all coverage
HealthAddress/Name ChangeOnline
HealthAffidavit Dependent Eligibility Tax Status
HealthContract Appointment Renewal
HealthNotification of Termination for Benefits
Tuition RemissionSubmit Tuition RemissionOnline
Flexible Spending Account (FSA)P&A Group Claim Form (Dependent Daycare and Healthcare)Online
Flexible Spending Account (FSA)Connect Your Care (Dependent Claim Form)
Flexible Spending Account (FSA)Connect Your Care (Health Claim Form)
State Retirement Pension (SRP)Pension Enrollment Form (Faculty / Exempt)
State Retirement Pension (SRP)Pension Enrollment Form (Nonexempt)
State Retirement Pension (SRP)Pension Pre-Retirement Checklist
Supplemental Retirement Annuity (SRA)Maryland Supplemental Retirement Plans 401 / 457b / 403b Rollover FormOnline
Supplemental Retirement Annuity (SRA)457b TIAA-CREF (SRA) Enrollment / Deduction Change Form
Supplemental Retirement Annuity (SRA)Maryland Supplemental Retirement Plan 401k / 457b / 403b Change FormOnline
Supplemental Retirement Annuity (SRA)Maryland Supplemental Retirement Plan 401k / 457b / 403b Enrollment FormOnline
Supplemental Retirement Annuity (SRA)403b Fidelity (SRA) Enrollment / Deduction Change Form
Supplemental Retirement Annuity (SRA)403b TIAA CREF (SRA) Enrollment / Deduction Change Form
Supplemental Retirement Annuity (SRA)457b Fidelity (SRA) Enrollment / Deduction Change Form
Optional Retirement Program (ORP)ORP Enrollment Forms
Optional Retirement Program (ORP)Checklist of ORP Pre-Retirement Action Items
Life/DisabilityUnum Life - LTD Enrollment
Life/DisabilityUnum LTD Highlight Sheet
Life/DisabilityUnum LTD Evidence of Insurability
Life/DisabilityUnum LTD Claim
Life/DisabilityUnum Life Coverage Highlights
Life/DisabilityUnum Life Beneficiary
Life/DisabilityMinnesota Life Evidence of Insurability
Life/DisabilityMinnesota Life Beneficiary Designation
Employment ContractContingent I (Health Benefits Eligible)
Employment ContractContingent I (Not Eligible for Health Benefits)
Employment ContractContingent II Nonexempt (Health Benefits Eligible)Download
Employment ContractContingent II Nonexempt (Not Eligible for Health Benefits)Download
Employment ContractContingent II Exempt (Health Benefits Eligible)Download
Employment ContractContingent II Exempt (Not Eligible for Health Benefits)Download