Leave of Absence Guides and Forms
|
| Type of Form |
Usage |
Download |
| Faculty Leave of Absence Guide |
guide |
PDF |
| FMLA Certification of Health Care Provider for Employee |
form |
WORD |
| FMLA Certification of Health Care Provider for Family Member |
form |
WORD |
| Physician's Certificate for Disability Benefits |
form |
PDF
|
| Physician's Certificate for Paid Family Leave |
form |
PDF |
| Physician's Extension for Disability Benefits |
form |
PDF |
| Staff Leave of Absence Guide |
guide |
PDF |
| Staff Request for Leave of Absence |
form |
WORD |
| Union Staff Request for Leave of Absence |
form |
WORD |
Life Insurance
|
| Type of Form |
Usage |
Download |
| MetLife Group Term Life Insurance Beneficiary Designation |
for adding or changing a beneficiary to your MetLife insurance policies |
PDF |
| MetLife Increase Amount Enrollment form |
for increasing amounts above the basic coverages |
PDF |
| MetLife Statement of Health |
form required for each Proposed Insured requesting insurance |
PDF |
| Metlife Supplemental Life Insurance Rates |
shows monthly costs for supplemental/optional term life insurance |
PDF |
Medical/Dental
|
| Type of Form |
Usage |
Download |
| Affidavit of Marriage |
to enroll spouse in any of the Santa Clara University sponsored health and welfare plans |
PDF |
| Affidavit of Registered Domestic Partner |
to enroll domestic partner in any of the Santa Clara University sponsored health and welfare plans |
PDF |
| Benefits Enrollment 2013 |
for new and current members during 2013 plan year; changes or waiver of medical/dental benefits |
PDF |
| |
| Blue Cross Member Claim |
for filing medical claims |
PDF
|
| Blue Cross Authorization |
employee's authorization for the use and/or disclosure of his/her protected Blue Cross health information |
PDF |
| |
| Kaiser Authorization |
employee's authorization for the use and/or disclosure of his/her protected Kaiser health information |
PDF |
| Health Insurance Waiver |
to waive medical insurance due to other group medical coverage |
PDF |
| |
Health Savings Account
|
| Type of Form |
Usage |
Download |
| Mellon HSA Solution Trustee-to-Trustee Transfer Form |
to initiate a trustee-to-trustee transfer of funds from an existing Health Savings Account (HSA) into the Mellon HSA Solution (for Blue Cross HSA (Compatible) High Deductible PPO members only) |
PDF |
| |
Pretax Medical Expense Account
|
| Type of Form |
Usage |
Download |
| Dependent Care Reimbursement Account Claim Form |
for expense reimbursement from dependent care reimbursement account(s) |
PDF |
| Flexible Spending Account Direct Deposit Authorization Form |
for direct deposit setup for your flexible spending account |
PDF |
| Health Care Reimbursement Account Claim Form |
for expense reimbursement from health care reimbursement account(s) |
PDF |
| Section 125 Enrollment |
for enrollment to medical expense and/or dependent care reimbursement account(s) |
PDF |
| |
Retirement
|
| Type of Form |
Usage |
Download |
| Fidelity 401a Beneficiary Designation |
for adding or changing a beneficiary to your 401a account |
PDF |
| Fidelity 401a Enrollment Guide |
for account transfers, rollovers and exchanges; enrollment guide and fund information provided |
PDF |
| Fidelity 403b Beneficiary Designation |
for adding or changing a beneficiary to your 403b account |
PDF |
| TIAA-CREF Beneficiary Designation |
for adding or changing a beneficiary to your 401a and 403b accounts |
PDF |
| |
| Salary Reduction Agreement 2013 with instructions |
for enrollment or changes to your voluntary tax-deferred Annuity Contributions and/or changes to your fund sponsor. |
PDF |
| |
Tuition Remission/Tuition Exchange
|
| Type of Form |
Usage |
Download |
| Intent to Register Application |
for eligible employees and/or their eligible dependents seeking Tuition Remission |
PDF
|
| Job-Related Education Verification Form |
to verify that graduate education benefit is job-related and not be included in the employee's taxable wages |
WORD
|
| Tuition Exchange Application Instructions |
information and instructions for completing the Tuition Exchange Application form |
HTML |
| Tuition Exchange Application Form |
form |
PDF |
| |
Other Benefits
|
| Type of Form |
Usage |
Download |
| Donation of Vacation Hours / Request for Additional Vacation Hours |
form |
PDF
WORD |
| Staff Request for Leave of Absence |
form |
WORD |
| Union Staff Request for Leave of Absence |
form |
WORD |
