Payroll and Employee Benefits
Open Enrollment 2012
Banner News
Benefits
Phased Retirement Program
Summary Plan Documents (SPDs) Effective 07/01/11
Voluntary Benefits 2011/2012
Forms
Payroll Forms Information
New Hire Forms 2011 - 2012
Payroll
Staff Directory
Frequently Asked Questions
Employee Self Serve (ESS)
News
Human Resource Services
Contact Us
A-Z Index
Payroll and Employee Benefits
Administration Building (AD), room G29
2000 W. University Ave.
Muncie, IN 47306
Hours:
8 a.m.-5 p.m. Monday-Friday
Phone:
765-285-8461
Fax:
765-285-6612
E-mail:
PEB@bsu.edu
Home
»
About
»
Administrative Offices
»
Payroll and Employee Benefits
» Forms
Forms
Insurance
Affidavit of Domestic Partner Relationship
(PDF)
Flexible Spending Dependent Debit Card Request
(PDF)
Flex Plan Guide
(PDF)
Flexible Benefit Plan Enrollment Form
(PDF)
FlexProTM Claim Form
(PDF)
Healthcare Enrollment Form
(PDF)
Healthcare Claim Form
(PDF)
Dental Claim Form
(PDF)
Prescription (Medco) Mail Order Form
(PDF)
Prescription (Medco) Claim Form
(PDF)
HSA Trustee Selection Form
(PDF)
Benefits at a Glance - 2010/2011
(PDF)
Benefits at a Glance - 2011/2012
(PDF)
HIPAA Privacy Release Form
(PDF)
BSU Life Insurance Beneficiary Change Form
(PDF)
Retiree Health Care Enrollment Form
(PDF)
Dependent Health Care Affidavit Form
(PDF)
Chronic Disease List
(PDF)
CIGNA Life Insurance Beneficiary Designation/Change Form
(PDF)
Retirement
Request to Participate in (Faculty) Phased Retirement Plan
(PDF)
Voluntary Retirement Savings
403(b) TDA (Tax Deferred Annuity) Agreement Form
(PDF)
403(b) Roth Agreement Form
(PDF)
457(b) Deferred Compensation Plan Agreement Form
(PDF)
Cancellation of Voluntary Deduction Authorization - 403(b) TDA/Roth and 457(b)
(PDF)
TRF Enrollment Form for New Members
(PDF)
PERF Post-Tax Voluntary Contribution to ASA
(PDF)
Fee Remission Forms
Fee Remission Form
(PDF)
Retiree Fee Remission Form
(PDF)
Payroll
Payroll Forms Information
Change of Address
(PDF)
BSU Direct Deposit Authorization
(PDF)
Federal W-4 Tax Form
(PDF)
State WH-4 Tax Form
(PDF)
12 Month Pay Option Authorization Form
(PDF)
Kronos Adjustment Form
(PDF)
Kronos Access Form
(PDF)
HSA Bank Payroll Deduction Form - 2011
(PDF)
HSA Bank Payroll Deduction Form - 2012
(PDF)
ACS Mellon HSA Solution Payroll Deduction Form - 2011
(PDF)
ACS Mellon HSA Solution Payroll Deduction Form - 2012
(PDF)
Savings Bond Authorization for Direct Deposit
(PDF)
B-25 Individual Absence Report Faculty-Staff
(PDF)
B-77 Individual Absence Report-Other
(PDF)