Forms Library

Benefits Administration (Medical, Life Insurance, Retirement, Tuition, Declarations etc)

Medical Insurance
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 Medical Enrollment (2009 Benefits Enrollment Form)
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 CareFirst BlueCross Blue Shield Claim Form
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 CareFirst BlueCross Blue Shield student certification
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 CareFirst BlueCross Blue Shield disability certification
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 Cigna Medical Claim Form
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 CIGNA student or disabled dependent certification
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 Health Insurance Waiver Form
Life Insurance
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 Beneficiary Designation Form for Basic Life Insurance
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 Beneficiary Designation Form for Supplemental Life Insurance
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 Evidence of Insurability
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 Short Term and Long Term Disability Enrollment Form 2009
Prescription Drug Program
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 Caremark Prescription Claim Form
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 Caremark Prescription Mail Order Form
Dental Insurance
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 Aenta Dental Claim Form
Flexible Spending Accounts
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 2008 Flexible Spending Account Request for Reimbursement Form
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 2008 Debit Card Substantiation Form
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 2009 Debit Card Substantiation Form
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 2009 Flexible Spending Account Request for Reimbursement Form
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 Flexible Spending Direct Deposit Authorization Form
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 Additional or Duplicate Debit Card Request Form
Retirement
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 Please visit Benefits Administration Home Page for Retirement Information
Tuition Benefits
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 Tuition Benefits Application
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 Faculty and Staff Certification of Graduate Tuition Benefits
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 Research Personnel Certification of Graduate Tuition Benefits
Leave
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 Leave Request Form
Declaration
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 Declaration of Common Law Marriage
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 Declaration of Domestic Partnership
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 Declaration of Marriage
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 Declaration of Dependent Children
HIPPA
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 Authorization for the Release of Protected Health Information
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 Plan Member Request for Account of Disclosures of Protected Health Information
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 Plan Member Request for Alternative Method for Confidential Communication of Protected Health Information
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 Plan Member Request to Access Protected Health Information
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 Plan Member Request to Correct or Amend a Record
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 Group Health Plan's Response to Request for Confidential Communications of Protected Health Information
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 Group Health Plan's Response to Request to Restrict Use or Disclosure of Protected Health Information
Transportation Benefits
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 Pre-tax Transportation Benefit Plan Enrollment/Change Form

Compensation Administration (Lump Sum Bonus Payment, Premium Pay)

Data Management (i9, Data Questionnaire, Data Change Request, Declaration of Marriage, Request Data Files)

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 I-9
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 Employee Data Questionnaire
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 Employee Data Change Request
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 Declaration of Marriage
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 BANNER Access Request Form
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 On-Line Directory Departmental Administrator Request Form - coming soon
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 Affiliate NetID Request Form
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 Request to Review Employee Record - coming soon
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 Request Employee Data File, Labels  or Report

Employee and Labor Relations (Performance Evaluations for Non-Exempt, Flex Time, Compressed Work Week, Telecommuting)

Recruitment and Employment Services (CIS, Temporary Wage Account, i9)

Miscellaneous (Direct Deposit, Exemption, D-4, VA-4)
 Division of Human Resources
 
Foggy Bottom Campus, 2033 K Street, NW, Suite 220, Washington DC 20052
Phone: (202) 994-9600 Fax: (202) 994-9619 Email: dhr@gwu.edu
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