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)