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) 
• HIPAA Privacy Release Form (PDF)
• Life Insurance Beneficiary Change Form (PDF)
• Retiree Health Care Enrollment Form (PDF)  

Retirement

• Request to Participate in (Faculty) Phased Retirement Plan (PDF)

Voluntary Retirement Savings

• NEW!! 403(b) and 457(b) Plan Salary Reduction Agreement - Fill In Version (PDF)
• NEW!! 403(b) and 457(b) Plan Salary Reduction Agreement - Paper Version (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)
• Kronos Adjustment Form (PDF)
• Kronos Access Form (PDF)
• Correcting Labor Form  (PDF)
• HSA Bank Payroll Deduction Form - 2013 (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)