FML Leave
w/o Pay (FMLWOP), Sick Leave (LWOP) Form
To arrange benefit payments while on LWOP.
FML
Request Form
To request leave for a serious health condition
(to be completed by employee).
FSA Claim
For Medical And Dependent Care Form
To submit a claim for your flexible spending
account.
FSA
Direct Deposit For Medical And Dependent Care Form
To establish direct deposits of flexible
spending account payments.
Student
Enrollment Verification/Dependent Health Care Eligibility
To verify student enrollment and/or to notify
employees of dependent (child) health care coverage eligibility.
UA
Choice Health Plan Enrollment Form (All Employees)
To enroll employee and dependents in UA health care plan.
UA
Choice Opt Out Form
To elect to opt out of UA health care coverage
and show proof of other insurance.
UA
Choice Supplemental Benefit Election Form
To add or delete employee-selected benefits
and/or deductions - i.e., FSA, AD&D, and other employee selected
deductions such as accounts payable, parking, United Way, etc.
VSP
Out-of-Network Reimbursement Form
Effective 7/1/04: To submit a claim to VSP
(vision vendor) for out-of-network provider reimbursements.
