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Human Resources
 

Benefit Forms

 

Accident Reporting Form (for Worker's Compensation)- This form is used to report accidents that occur on campus property.

Alternate-Reduced Work Arrangement - This form is used by employees and supervisors to create an agreement and to describe a work schedule that will vary from the employee's typical work week.  This could be on a long-term or short-term basis.

Basic Retirement Plan Form (12kb) - This form is used to designate the funds for the Skidmore College Basic Retirement Plan.

Blue Shield Forms

Blue Shield of Northeastern NY Direct Claim Form- This form is used to receive direct reimbursement from Blue Shield of Northeastern NY (Skidmore PPO Plan).

Blue Shield of Northeastern NY Claim Form for Direct Reimbursement for Alternative Health Benefits - This form is to be used for direct reimbursement from Blue Shield of NENY (Skidmore PPO Plan) for any service under Alternative Health Benefits: Acupuncture; Fitness Center Membership; Homeopathic Care; Hypnotherapy for weight control or smoking cessation; Massage Therapy; and Nutritional Counseling.

Blue Shield of Northeastern NY Enrollment Application/Change Form - This form is used to enroll or make changes to your information with the Skidmore College PPO Plan.

CDPHP Enrollment Application/Change Form - This form is used to enroll or make changes to your information with CDPHP.

Dental Claim Form - This form is used to submit dental claims to the provider.

Dental Plan Application - This form is used if you are selecting Dental Plan A or B as your dental coverage.

Disability Reporting Form - This form is for employees and supervisors to report a non-work related disability.

Domestic Partnership Forms

Domestic Partner Affidavit - This form is used to add and verify a Domestic Partner if you are selecting Domestic Partner coverage.

Domestic Partner Dependent Children Eligibility Certification - This form is used to enroll a Domestic Partner's qualified dependent children, if you selected Domestic Partner coverage.

Domestic Partner Termination Form - This form is used to remove a Domestic Partner, if you selected Domestic Partner Coverage

External Tuition Grant Application - This form is used by Skidmore employees to apply for the External Tuition Grant for their legally dependent children attending a college other than Skidmore.

Faculty Parental Leave Request - This form is used by Skidmore faculty to apply for parental leave.

FMLA Forms

FMLA Employee Form - This form is used by physicians or practitioners to certify the reason for the leave, and is specifically for the serious health condition of an employee.

FMLA Family Member Form - This form is used by physicians or practitioners to certify the reason for the leave, and is specifically for the serious health condition of a family member.

FMLA Request Form - This form is used by Skidmore Employees to request leave covered by the Family and Medical Leave Act.

Flexible Spending Account Forms - These forms are used by employees to request reimbursement from their Flexible Spending Accounts (Health Care Spending and Dependent Care Spending) for services incurred.  

Benefit Strategies FSA Reimbursement Form 2014

R&K Health Care Reimbursement Form 2013  

R&K Dependent Care Reimbursement Form 2013

Internal Tuition Grant Application - This form is used for employees who wish to apply for the Internal Tuition benefit.

Life Insurance Forms

Life Insurance Beneficiary Designation Form - This form is used by employees who wish to change their group term life insurance beneficiary.

Life Insurance Enrollment Form - This form is used by employees at date of hire or open enrollment who wish to enroll in Dependent Life Insurance for the 1st time.  It is also used by employees during open enrollment who elect to increase their Supplemental Life Insurance by more than one level.

Life Insurance Evidence of Insurability Form - This form is used by employees during open enrollment who wish to enroll in Dependent Life Insurance or Supplemental Life Insurance, or increase their current Supplemental Life Insurance by more than one level.

MVP Enrollment Application/Change Form - This form is used to enroll or make changes to your information with MVP.

Prescription Plan Forms

Prescription - Medco Direct Reimbursement Claim Form - This form should be used by employees of Local 200United who are participants in the healthcare plan provided by 1199, who paid for their prescription, and are requesting reimbursement from Medco (Pharmacy Provider).  It can also be used as a coordination of benefit form if the employee's covered dependent also has prescription coverage elsewhere.

Prescription - Catamaran Mail Order Form
(formerly known as informedRx) - This form should be used by employees and retirees under the age of 65, or their dependents, who are participants in the Skidmore College PPO Plan to fill their prescription coverage through mail order.  Mail order prescriptions are for a 90 day supply with the copay equivalent to 2 retail copays, saving one month copay.

Prescription - Catamaran Direct Reimbursement Claim Form
(formerly known as informedRx) - This form should be used by employees and retirees under the age of 65, or their dependents, who are participants in the Skidmore College PPO Plan for reimbursement of any eligible prescription drug costs paid in full out-of-pocket.

Prescription - FOR RETIREES
SilverScript/Caremark Mail Order Form
- This form should be used by retirees who are at least age 65, and long-term disability participants who are covered by Medicare, who are covered through the Blue Shield of NENY PPO Plan for medical benefits and SilverScript for their prescription drug coverage.  Mail order prescriptions are for a 90 day supply with the copay equivalent to 2 retail copays, saving one month copay.

Prescription - FOR RETIREES (Medicare Eligible)
SilverScript/Caremark Prior Authorization Form
- This form should be used by retirees and long-term disability participants who are Medicare eligible and are covered through Blue Shield of NENY for their medical bills and SilverScript for their prescription drug coverage.  There may be times when you will need prior authorization to receive a specific drug.

Supplemental Retirement Account - This form is used by employees who wish to enroll in a Supplemental Retirement Account (SRA) or change the amount of their contributions. Changing fund selection/allocation must be done through the company you have selected for your SRA.

2014 Supplemental Retirement Account - Salary Reduction Form  

2015 Supplemental Retirement Account Salary Reduction Form

Vanguard Forms

Vanguard Address Change Form - This form is to be used when you wish to change your address for your Vanguard Retirement Account.  Please complete, sign and return the form to Human Resources.

Vanguard Beneficiary Change Form - This form is to be used when you wish to change your beneficiary for your Vanguard Retirement Account.  Please complete, sign and return the form to Human Resources.

Vanguard Installment Form - This form is to be used for anyone who has left employment and is requesting income in the form of installment payments.  This form is to be used in conjunction with the Vanguard Distribution Form.

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