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Benefits Forms

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General

Change of Name/Address Form

Tuition Remission & Reimbursement

Tuition Remission 
Tuition Reimbursement

Health Benefits

Plan Year 2017 Regular Employee Enrollment Form
Plan Year 2017 Direct Pay PT-Contractual/COBRA/LAW Enrollment Form
Plan Year 2017 Contractual/Variable Enrollment Form
Plan Year 2017 Retiree Enrollment Form
HIPPA Authorization Form
CHIP Acknowledgement 

Affidavit/Dependent/Certification Forms

Disabled Dependent Certification Form 
Affidavit for Dependent Eligibility and Tax Status 

Life Insurance

Beneficiary Form for UNUM Term Life Insurance 
Minnesota Life Insurance Beneficiary Form
Minnesota Life Statement of Health Form
UNUM Term Life Enrollment Form 

Disability

UNUM Long Term Disability Enrollment Form 
UNUM Claim for Income Protection Benefits 

Accidental Death & Dismemberment

Minnesota Life Accidental Death & Dismemberment Beneficiary Form

Flexible Spending Account

Flexible Spending Account Log-in
Flexible Spending Claim Form

Leave

Leave forms are available here.

Retirement Forms

Retirement Plan Selection Form 
Vendor Selection/Change Form 
ORP Retiree Health Benefits Handbook 
ORP Retiree Forms Packet 
Pension Retiree Checklist
ORP Retiree Checklist 

Supplemental Retirement Account Forms

SRP Supplemental Retirement EZ Enrollment Form 
MSRP Supplemental Retirement Plans Deferral Change Form 
TIAA-CREF 403 (b) 
Fidelity 403 (b) 
TIAA-CREF 457 (b) 
Fidelity 457 (b)