Human Resources Home

Personnel

Services

Policies

Resources

Administration & Finance Division
 

Benefits

Collective Bargaining Agreements

Jobline (Job Openings)

Job Opportunities at the Research Institute

Social Equity

Payroll

Acts of Hate and Intolerance

Employee Self Service

Benefit Forms:

Beneficiary Forms:

• State Employees' Retirement System (SERS)
• Public School Employees' Retirement System (PSERS)
• Alternative Retirement Plan (ARP)
• Basic Group Life Insurance (BGLI)
• Voluntary Group Life Insurance (VGLI)
• Deferred Compensation (457)
• Tax Sheltered Annuities (403(b)) - Contact your TSA carrier directly for beneficiary changes.

Health Insurance Plans:

Health Plan Forms for Faculty, Managers, Police, Coaches and Nurses:

• PASSHE Health Insurance Enrollment/Change Form 
• How to complete the SSHE Health Enrollment Form - Adding/Removing Dependents
• PASSHE Student Certification Form
• Member Submitted Claim Form (Indemnity and PPO Members)
• Prescription Drug Claim Form
• Vision Claim Form (Managers, Police, Coaches and Nurses ONLY)
• Dental Claim Form (Managers, Police, Coaches and Nurses ONLY)
• Faculty Dental, Vision and Hearing Forms are available at www.pafac.com

Health Plan Forms for AFSCME, SCUPA, PSSU and PDA:

• PEBTF-2 Health Insurance Enrollment/Change Form
• PEBTF-7 Student Certification Form
• How to complete the PEBTF Health Insurance Enrollment Form
• PEBTF-2A Coordination of Benefits Form
• PEBTF-11 Declaration of Spouse Health Care Coverage Form - Employees Active on July 31, 2003
• PEBTF-11 Declaration of Spouse Health Care Coverage Form - Employees Hired On or After August 1, 2003
• Medical Expense Claim Form for PPO and Traditional Plans
• United Concordia Dental Plan Claim Form
• Medco Prescription Drug Claim Form
• Allergenic Extract Claim Form
• Hearing Aid Claim Form

Flexible Spending Accounts:

Flexible Spending Enrollment forms - for all employees:

• Enrollment Form for Medical Reimbursement Account
• Enrollment Form for Dependent Care Reimbursement Account

Flexible Spending Reimbursement forms - for all employees:

• Reimbursement Form for Medical Reimbursement Account Interactive
• Reimbursement Form for Dependent Care Reimbursement Account  Interactive

Flexible Spending Account Status Change forms - for all employees:

• Status Change Form for Medical and Dependent Care Reimbursement Account

FMLA (Faculty, Managers, Police, Nurses, Coaches, SCUPA & PDA):

• Serious Health Condition Certificate - Employee
• Serious Health Condition Certificate - Family Member

Sick, Parental and Family Care Leave (SPF) (AFSCME & PSSU):

• Request for Sick, Parental or Family Care Absence
• Serious Health Condition Certification

Tuition Waiver:

• IUP Tuition Waiver Form
• Tuition Waiver Form for Other SSHE Schools (Faculty, Managers and Coaches ONLY)

Leave Donation Program (AFSCME, PSSU, SPFPA, Managers):

• Request to Donate Leave Form
• Request to Receive Leave Donations Form

Retirement:

• Retirement Program Election Form
• Alternative Retirement Plan (ARP) Allocation Change Form
• State Employees Retirement System (SERS) Forms
• Public School Employees Retirement System (PSERS) Forms
• Tax-Sheltered Annuity (403(b)) Salary Reduction Agreement Form
• Deferred Compensation (457) Forms

Basic Group Life Insurance Program:

• Beneficiary Change Form

Voluntary Group Life Insurance Program:

• Enrollment/Change Form - For Enrollment and Beneficiary Changes
• Medical History Statement
• VGLIP Life Insurance Conversion Application
• VGLIP AD&D Conversion Application
• VGLIP Portability Application - Family
• VGLIP Portability Application - Former Dependent Child Only

Long-Term Disability Insurance Program:

• Enrollment Form
• Evidence of Insurability Form

Miscellaneous Forms

• Auxmail - Email Account Application for Retiring Employees

Home