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HR Employee Forms

Health Forms:

Form Name Available Formats
(Icon Legend)
Form Descriptions

Blue Cross Health Care Claim Form

Adobe PDF format file For Blue Cross health care claims.
Caremark Prescription Claim Form Adobe PDF format file For Caremark pharmacy claims.
COBRA Rights and Responsibilities Summary Adobe PDF format file Summary of COBRA Rights and Responsibilities.

Financially Interdependent Partners Explanation

Adobe PDF format file To explain and determine FIP eligibility.

Financially Interdependent Partners Statement

Adobe PDF format file To declare FIP eligibility.
FML: Q & A's
Adobe PDF format file Questions and answers regarding Family Medical Leave (FML).
FML Request Form Adobe PDF format file To request FML leave for a serious health condition (to be completed by employee).
FML: Certification of Health Care Provider for Employee's Serious Health Condition External Site To support an employee's FMLA leave request due to the employee's own serious health condition (to be completed by the employee, employer, and the employee's health care provider).
FML: Certification of Health Care Provider for Family Member's Serious Health Condition External Site To support an employee's FMLA leave request due to a family member's serious health condition (to be completed by the employee, employer, and the family member's health care provider).
FML: Certification of Qualifying Exigency for Military Family Leave External Site To support an employee's FMLA leave request due to a qualifying military exigency (to be completed by the employee and employer).
FML: Certification for Serious Injury or Illness of Covered Servicemembers - for Military Family Leave External Site To support an employee's FMLA leave request due to the serious health condition of a covered servicemember (to be completed by the employee or covered servicemember, employer, and DOD health care provider).

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.
Student Enrollment Verification/Dependent Health Care Eligibility Adobe PDF format file To verify student enrollment and/or to notify employees of dependent (child) health care coverage eligibility.
UA Choice Enrollment Guide
(For coverage effective as of July 1, 2009.)
Adobe PDF format file UA Choice Enrollment Guide for plan period of July 1, 2009, through June 30, 2010.
UA Choice Health Plan Enrollment Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To enroll employee and dependents in the UA health care plan for the plan period of July 1, 2009, through June 30, 2010.
UA Choice Opt Out Form - FY10
(For plan period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To elect to opt out of UA health care coverage during the plan period of July 1, 2009, through June 30, 2010.
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.
VSP Out-of-Network Reimbursement Form Adobe PDF format file Effective 7/1/04: To submit a claim to VSP (vision vendor) for out-of-network provider reimbursements.

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