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About the Town
Academic Year Calendars
Housing and Residence Life
People and Place Finder
Summer Session Courses
Act 34 Clearance (SP 164)
Request for Criminal Record Check
Address Change Form
Alternative Retirement Plan Representatives
For those enrolled in ARP retirement - AIG Valic, Fidelity, ING & TIAA-CREF
Direct Deposit Form
Can have pay direct deposited in up to 2 accounts
If checking account, voided check should be included with this form.
Family Medical Leave (FMLA)
Family Medical Leave - Employee Form
Family Medical Leave - Family Member Form
Flexible Spending Accounts
Reimbursement Form for Dependent Care Reimbursement Account
Reimbursement Form for Medical Reimbursement Account
Highmark Blue Shield Indemnity Plan
NO NEW ENROLLMENTS
Plan Updated 07/01/08 (comprehensive major medical)
Not for PEBTF
Highmark PPOBlue Benefits Grid
PPO Preventive Schedule
Not for PEBTF
lue Shield Claim Form
PASSHE Employee Member Submitted Claim Form -
NOT FOR PEBTF
PASSHE Notice of Privacy Practices
SEAP HIPAA Notice
Life Insurance (Basic Group) Beneficiary Form
Beneficiary updates for Employer-paid life insurance through Prudential.
Submit directly to Prudential.
Long-Term Disability Evidence of Insurability
To be completed for those electing LTD coverage after 31 days of hire date. Complete form and submit to Human Resources for handling.
Long-Term Disability Claim Form
Instructions for filing of LTD claim
PASSHE Benefits Enrollment/Change Form
APSCUF, Management, Coaches, OPEIU & SPFPA
To update information for PASSHE employees. Submit to HR Office for processing.
PEBTF-2 Enrollment/Change Form
To update information for PEBTF employees. Submit to HR Office for coding and forwarding to PEBTF.
AFSCME & SCUPA
PEBTF Student Certification Form
PEBTF Student Certification Instructions
For first-time or mid-year certification.
PEBTF January Student Certification Form
PEBTF January Student Certification Instructions
Completion of Certification & Verification required in January.
Retirement Plan Information
Comparison of Retirement Plans Guide
ARP Company Comparison Guide
Retirement Plan Allocation Change Form
- ARP participants only!
If enrolled in the Alternate Retirement Plan, allocation changes between companies can be made twice during a calendar year.
Salary Deferral Agreements
457 vs 403(b) Plan Comparison
Tax Sheltered Annuities
Plan Limits for 2009
Deferred Compensation Plan Program Details
457(b) Plan - Great West Retirement Services
KU Representative: Jaime Robbins
1-866-737-7457, press 2 ext 62229
Participant Enrollment Form
Application for Catch-Up
Personal Info. Change Request
Tax Deferral of Leave Payments
As a result of the Economic Growth & Tax Relief Reconciliation Act of 2001 (EGTRRA), employees may defer leave payments received upon retirement/termination to the Deferred Compensation Plan (457 Plan) administered by Great West -
(Use Salary Deferral Agreement form above.)
TSA Salary Reduction form
TSA Vendor Listing
TIAA-CREF Retirement Online Enrollment
Select "ENROLL NOW" - **USE ACCESS CODE PA100298
To be used for Retirement Annuities only - not TSA's
For tuition waiver information and related forms
Voluntary Group Life Brochure
Employee-paid additional life insurance with CIGNA.
Voluntary Group Life Enrollment/Change Form
To be used for medical underwriting if coverage exceeds guaranteed amount or if enrolling after 31 days of hire.
W-4 Form - 2009
Update Federal Withholding Information
Workers Comp. Panel
Listing of panel physicians for work-related injuries
Stratton Administration Center
Text Only Version