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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- 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 - This form is used to enroll or make changes to your information with the Skidmore College PPO Plan.

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

Disability Reporting - 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 - 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 - 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 - 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 - 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

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 - This form is used by employees who wish to change their group term life insurance beneficiary.

Life Insurance Enrollment - 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 - 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 Forms

Alternative Health Benefit Reimbursement form - This form is to be used for direct reimbursement from MVP 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.

Authorization to Disclose Information - This form is used to give MVP permission to share health information with a third party.

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

Medical Claim Reimbursement  - This form is used to request reimbursement for medical expense.

Mental Health/Substance Abuse Treatment Claim - This form is used to file coverage claims for non-participating mental health/substance abuse treatment providers.

Prescription Plan Forms

Optum Mail Order - This form should be used by employees and their dependents who are participants in the Skidmore College PPO or EPO Plans to fill their prescription coverage through mail order. Mail order prescriptions are for a 90 day supply with the copay equivalent to 2.5 retail copays, saving a half month's copay.

Optum Direct Reimbursement Claim- This form should be used by employees or their dependents who are participants in the Skidmore College PPO or EPO Plan for reimbursement of any eligible prescription drug costs paid in full out-of-pocket.

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.

Supplemental Retirement Account Salary Reduction Form

Vanguard Forms

Vanguard Address Change - 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 - 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 Enrollment/Change - This form is to be used when you wish to enroll in a Vanguard Retirement Account, or make changes to your Vanguard Retirement Account. Please complete, sign and return the form to Human Resources.

Vanguard Installment - 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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