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	Act 34 Clearance (SP 164) Request for Criminal Record Check Address Change Form   Blue Shield (Highmark)Claim Form PASSHE Employee Member Submitted Claim Form - NOT FOR PEBTF 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 HIPAA NOTICES PEBTF HIPAA 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 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. PASSHE Benefits Enrollment/Change Form APSCUF, Management, Coaches, OPEIU & SPFPA To update information for PASSHE employees.  Submit to HR Office for processing. Salary Deferral Agreements 457 vs 403(b) Plan Comparison Tax Sheltered Annuities Plan Limits for 2008 Deferred Compensation Plan Program Details 457(b) Plan - Great West Retirement Services KU Representative:  Melanie Thomas - 1-866-737-7457 ext 22 melanie.thomas@gwrs.com Informational Sheet 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 Tuition Waivers 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 - 2008 Update Federal Withholding Information Workers Comp. Panel Listing of panel physicians for work-related injuries   Personnel/Payroll Stratton Administration Center Room 109

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