Benefits Forms for Active Employees

Absence Reports/Timesheets

• Absence Report for Classified Employees Form BS-59
• Absence Report for Certificated Employees Form BS-137
• Classified Employees Differential and Overtime Timesheet BS-139
• Student Help Timesheet Form BS-91
• Temporary Classified Timesheet Form BS-68

Adjunct Insurance Forms

• Adjunct Request to Continue Medical Coverage (LRCFT MOU)

Domestic Partner Forms

• Domestic Partner Affidavit of Domestic Partnership Form BS-209
• Termination of Domestic Partnership

HSA/FSA Forms

Flexible Spending Accounts (FSA)

• Basic CDA – Dependent Care Eligible Expenses
• Basic CDA – Dependent Care Contract
• Basic CDA – MyCash Account
• Basic CDA – FSA Participant Enrollment Guide
• Basic CDA – Direct Deposit Request Form
• Basic CDA – Reimbursement Request
• Basic CDA – Participant Reference Guide
• Basic CDA – Participant Experience Flyer
• Basic CDA – Medical FSA Election Worksheet
• Basic CDA – Orthodontia Contract

Long-Term Care Insurance Forms

Class 001 – Classified Staff Working at Least 20 Hours Per Week

• Class 001 Long-Term Care Enrollment Form
• UNUM Checklist of Delivered Forms
• Long-Term Care Medical Questionnaire
• Request to Change Long-Term Care Coverage
• Election to Continue Long-Term Care Coverage

Class 002 – Certificated Staff Working at Least 50%

• Class 002 Long-Term Care Enrollment Form
• UNUM Checklist of Delivered Forms
• Long-Term Care Medical Questionnaire
• Request to Change Long-Term Care Coverage
• Election to Continue Long-Term Care Coverage

Class 003 – Adjunct/Permanent Part-Time Staff (Not Qualified for Class 001 or 002)

• Class 003 Long-Term Care Enrollment Form
• UNUM Checklist of Delivered Forms
• Long-Term Care Medical Questionnaire
• Request to Change Long-Term Care Coverage
• Election to Continue Long-Term Care Coverage

Leave Forms

Catastrophic Leave

Classified Staff

• Application for Catastrophic Leave for Classified and Management Employees BS-185
• Catastrophic Leave Medical Certification Form BS-184

Certificated Staff

• Extended Catastrophic Leave Application for Faculty Form BS-200
• Authorization for Release of Faculty Medical Information Form
• Extended Catastrophic Leave Medical Certification for Faculty Form BS-201

COVID-19 Leave Certification

• Employee Certification of Need for Supplemental Paid Sick Leave – Updated January 2023

Five Month Law

• Five Month Law Physician's Verification Form
• Verification of Illness Form –  Not for use for 5 Month Law or Catastrophic Leave

Family Medical Leave Act (FMLA)

• FMLA Request Form BS-186
• Certification of Health Care Provider for Employee’s Serious Health Condition
• Certification of Health Care Provider for Family Member’s Serious Health Condition

Sick Leave and Vacation Forms

• Sick Leave Transfer Request Form BS-195
• Vacation Disposition Form BS-64

New Hire Forms

• ACA Marketplace Notice
• Acceptance of COBRA Initial Notification Receipt Form BS-181

Retirement Savings Plan Forms

403B Savings Plan

• Online 403B Salary Reduction Agreement Form

457 Savings Plans

• Online 457 Salary Reduction Agreement Form

Retirement Savings Distributions

• Envoy Services – Instructions for Distributions/Withdrawals/Loans
• Envoy Services – Transaction Request Form