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HR Employee Forms

Flexible Spending Account Forms:

Form Name Available Formats
(Icon Legend)
Form Descriptions

FSA Claim For Medical And Dependent Care Form

Adobe PDF format file To submit a claim for your flexible spending account.
FSA Direct Deposit For Medical And Dependent Care Form Adobe PDF format file To establish direct deposits of flexible spending account payments.
UA Choice Supplemental Benefit Election Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To add or delete employee selected benefits and/or deductions (e.g. FSA, AD&D, Supplemental Life) during the plan period of July 1, 2009, through June 30, 2010.
UA Supplemental Life Evidence of Insurability (EOI) Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file Employees electing more than $200,000 in supplemental life coverage are required to complete the evidence of insurability form and submit it to their HR office along with with the UA Choice Supplemental Benefit Election Form.

 

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